The Department of Justice (DOJ) is continuing its scrutiny of groups that provide Medicare Advantage plans. Just over a year ago, the Office of Inspector General reported that these plans led to billions in risk-adjusted payments that were not supported by specific services provided to patients – ultimately leading to allegations of health care fraud. This report has likely led to increased scrutiny of these programs, as recently highlighted in a case out of Texas.
How did the lawsuit begin?
The Department of Justice (DOJ) recently filed a lawsuit after a former service provider for a local Texas Company stated the organization used nurses and patients to fraudulently receive billions in claims from the Centers of Medicare and Medicaid Services (CMS). This whistleblower worked with the company, Texas Health Management, during the time it was allegedly filing these false claims.
The company at the time was a small part of a larger group, Cigna. Once the whistleblower moved forward with the claims, the DOJ joined the lawsuit.
What were the allegations?
Essentially, the government has accused the group of claiming inappropriate risk scores to illegally increase their reimbursement rate. Groups determine these risk scores after an in-person meeting between the patient and a medical professional. The score will vary depending on a number of considerations. Essentially, the older and sicker the patient, the higher the score.
The higher the risk score, the higher the payment from CMS.
In order to receive reimbursement for these scores, the CMS generally requires the medical professional not only conduct a face-to-face visit but also provide medical care to the patient. The government states this group sent nurses to conduct the face-to-face visits but instructed the nurses to refrain from providing medical care. If they can substantiate this claim the government could have a successful case against the accused. The business is currently fighting the allegations.