The Centers for Medicare & Medicaid Services (CMS) recently announced a proposed rule that would restrict a widespread billing practice used by Medicare Advantage plans to inflate payments from the federal government. The proposal signals that the government is committed to combating risk adjustment fraud, an area with substantial and growing False Claims Act exposure. What CMS Proposed On January 26, 2026, CMS released its 2027 Advance Notice, which included a proposal to exclude patient … [Read more...]
Report Says Medicare Part C Insurers Are Pocketing Billions Through Risk Adjustment Schemes
Medicare Advantage, or Part C, was created with the idea that private insurers could provide more cost-effective healthcare than traditional Medicare. But while the program has become popular — it’s the largest taxpayer-funded health insurance program in the United States with a $450 billion annual budget and more than 31 million participants — it is losing billions to fraud. As recent False Claims Act settlements and a recent report in the Wall Street Journal show, one of the costliest … [Read more...]
Government watchdog flags risk-adjusted Medicare Advantage payments
In September, the U.S. Department of Health and Human Services’ Office of Inspector General issued a report raising concerns that some Medicare Advantage companies inappropriately used chart reviews and health risk assessments, or HRAs, to receive higher risk-adjusted payments. The OIG found that 20 of the country’s 162 MA companies accounted for a disproportionate share of $9.2 billion in payments from diagnoses that were only reported on chart reviews and HRAs. Of the 20 companies, one … [Read more...]
Keller Grover, Constantine Cannon and Kleiman Rajaram Announce Record $90 Million False Claims Act Whistleblower Settlement with Sutter Health
Sutter Health settles closely watched whistleblower lawsuit alleging it violated the False Claims Act by submitting inaccurate and unsupported medical information on tens of thousands of patients enrolled in Medicare Advantage. SAN FRANCISCO, Aug. 31, 2021 /PRNewswire/ -- Keller Grover, Constantine Cannon, and Kleiman Rajaram announce the landmark $90 million False Claims Act settlement against Sutter Health on behalf of their whistleblower client, Kathy Ormsby, over allegations … [Read more...]
Five Ways Hospice Providers Use Terminally Ill Patients to Rip Off Taxpayers
Hospice care is the provision of specialized palliative treatment for terminally ill patients, focused not on curing them but making their last days as comfortable as possible. Hospice has gone from a grassroots movement on the outskirts of the U.S. medical establishment to a massive, multibillion-dollar industry. And as it has come of age, it has increasingly attracted the same type of fraud, waste, and abuse that plagues U.S. healthcare at large. Hospice treatment has been covered by … [Read more...]