MedPage today story.
The Western Health Insurance provider in New York agreed to the elderly and the CEO of the arm of medical analyzes to pay a total of up to 100 million dollars to settle the allegations of the Ministry of Justice for fraudulent bills on the health conditions that were exaggerated or not exist.
The Independent Health Association in Bovalo, which runs two plans for Medicare Advantage, will pay up to $ 98 million. Petsey Jafni, CEO of DXID Medical Record Review Company, will pay $ 2 million, according to the settlement agreement. I do not admit violations.
” Announcing the settlement On December 20.
“The assurances by the Ministry of Justice are only allegations, and there was no decision of responsibility. This settlement is not a recognition of any violations; it allows us instead to avoid additional disruption, its expenses, and the uncertainty in a matter of a matter of fatty music,” Frank Sava, the official spokesman for the independent health.
Under the settlement, “Independent Health” will make “guaranteed payments” worth $ 34.5 million in installments from 2024 to 2028. Whether pay the maximum amount in the settlement, depends on the financial performance of the health plan.
Michael Ronikir, the lawyer for the violations of the Teresa Ross, described the settlement as “historic”, saying that it was the largest batch so far through a health plan that depends only on allegations of fraud on violations. He was also one of the first to accuse a data mining company of helping the health plan excessively.
The settlement is the latest in a vortex of the procedures of the violations that claim the fraud of bills by the medical care feature. Medicare Advantage plans are special health plans that cover more than 33 million members, which constitute more than half of the people who are qualified to obtain medical care. they It is expected to grow more Under the Trump management received.
But with the popular Medicare Advantage acquisition, the CMS organizers have struggled to prevent health plans from exaggerating how their patients’ revenues are strengthened.
The amounts like Ross, a former medical coding professional, helped the government of hundreds of millions of dollars in excessive payments linked to the alleged coding violations. Ross will receive at least $ 8.2 million, according to the Ministry of Justice.
Ross said that CMS “created a bonus” of the health plans that added the symbols of medical diagnosis while reviewing the patient plans – and whether these symbols are accurate or not “it does not seem to bother some people.”
Ross told Ross KFF Health News In an interview.
Data extraction
Ministry of Justice Civil complaintAnd presented in September 2021, was not an ordinary matter in targeting the data analysis project – and its highest executive – due to the payment of payments of leaders.
DXID Specialized in Mining Electronic Medical Records to capture new diagnoses for patients – a pocket up to 20 % of the money she gave birth to the health plan, according to the case, which said independent health used the company from 2010 to 2017.
GAFFNEY has developed its services to Medicare Advantage plans as “very attractive to access”, according to the complaint of the Ministry of Justice.
Jafni said, according to the complaint: “There are no fees for submitting, we do not receive their salaries until you get their salaries and work on a percentage of the actual recitations that have proven their usefulness.” “The settlement is not acceptance of any responsibility by Mrs. Jafni. Settlement of the conflict resolution and provides a closure to the parties,” Javini’s lawyer, Timothy, said in a statement.
“A ton of money”
CMS uses a complex formula that pays higher health plans for sick patients and less for people in good health. Health plans should retain medical records that document all the diagnoses they highlight for payment.
Independent health has violated these rules through the medical care bill for a group of medical conditions that were exaggerated or not supported by the patient’s medical files, such as bills to treat chronic depression that was solved, according to the complaint. In one case, a 87 -year -old man was encoded as suffering from “severe depression disorder” although his medical records indicated that the problem was “passing”, according to the complaint.
Dxid also cited chronic kidney disease or kidney failure “in the absence of any documents indicating that the patient has suffered from these cases,” according to the complaint. The previous conditions, such as heart attacks, have also been coded, which have not required any current treatment, according to the Ministry of Justice.
The lawsuit claims that Jafni said that the diagnoses of kidney failure were “worth a lot of money for IH [Independent Health] The majority of people (more) 70 have some level. “
Russian The case of those reported to the violations was provided In 2012 against Group Health Cooperookive in Seattle, one of the oldest managed care groups in the country.
Ross, the former medical coding director there, claimed that DXID made more than 30 million dollars in the claims of diseases – many of which were in effect – on behalf of the group’s health for the year 2010 and 2011.
Collective health, now known as the Kaiser Foundation’s health plan in Washington, denied any violations. but settle The civil case in November 2020 approves $ 6.3 million. The Ministry of Justice filed a second complaint in 2021, against independent health, which also used DXID services.
Ross said that she lost her job after her innovation was generally in 2019 and she was unable to secure another in the field of medical coding.
“It was sometimes difficult, but we went through it,” she said. Ross, 60, said that she is now “retired happily.”
False claims
The informed by the violations under the law of wrong claims, a federal law dating back to the civil war that allows ordinary citizens to expose fraud against the government and participate in any recovery.
At least twenty of these claims, dating back to 2009, targeted Medicare Advantage plans for excessive medical conditions, a practice known in this industry as “height”. The total number of previous settlements of these cases was more than $ 600 million.
The informants played a major role in holding health insurance companies accountable.
While dozens of CMS audits have concluded that health plans have imposed the government on the government, its agency has He did little to recover Money for the US Treasury.
In a sudden work in late January 2023, CMS announced It will settle on a small part of tens of millions of dollars in excess payments that have been discovered through its audit operations dating back to 2011 and do not impose major financial penalties on health plans until a tour of the 2018 audit operations is made, which has not yet been done. Exactly how much plans that will end will be clear.
“I think CMS should do more,” said Max Voldman, a Russian lawyer.
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