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 Medicare Advantage fraud.As recent False Claims Act settlements and a recent report in the Wall Street Journal show, one of … [Read more...]
Medicare Advantage Fraud: Sutter Health’s $90 Million Whistleblower Settlement
A record $90 million False Claims Act settlement over Medicare Advantage fraud allegations, obtained for the government as a result of a whistleblower lawsuit by a Keller Grover client, was among the cases highlighted by the U.S. Department of Justice in a recent announcement touting its 2021 recoveries under the Act. On Feb. 1, Acting Assistant Attorney General Brian M. Boynton announced DOJ had recovered more than $5.6 billion from False Claims Act settlements and judgments in the 2021 … [Read more...]
Telemedicine Fraud Remains a DOJ Priority — and Whistleblowers Are Key
As telemedicine fraud remains a top enforcement priority of the U.S. Department of Justice, whistleblowers can play a key role in helping the government recoup taxpayer dollars lost to fraud.In September 2021, the DOJ announced charges against more than 43 individuals in 11 judicial districts. The government alleged those individuals took part in schemes involving telemedicine leading to more than $1.1 billion in allegedly false and fraudulent claims being submitted to Medicare and other … [Read more...]
Medicare Advantage Risk Adjustment: Watchdog Flags Chart Reviews and Health Risk Assessments
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 payments under Medicare Advantage risk adjustment. 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. … [Read more...]
Healthcare Fraud Whistleblower Cases Stay a DOJ Priority
The U.S. Department of Justice’s Civil Division remains focused on prosecuting healthcare fraud, including healthcare fraud whistleblower cases, despite a changing of the guard in Washington, a DOJ official told a group of lawyers in late June.In an address to the American Health Law Association’s Annual Meeting, Michael Granston, deputy assistant general for the DOJ’s Commercial Litigation Branch, emphasized that prosecuting such cases remains a top priority for the department under the … [Read more...]