A Medicare Advantage plan will pay $22.5 million to settle allegations that it systematically reviewed patient charts to tack on additional charges before submitting claims to Medicare, federal law enforcement officials announced this week.
The Department of Justice accused Maine-based Martin’s Point Health Care of violating the False Claims Act by submitting inaccurate diagnosis codes for its plan enrollees in Maine and New Hampshire to increase reimbursement.
Medicare Advantage plans have been accused of taking higher profits than earned, while limiting patient access to care and offering providers such as skilled nursing facilities cut rates for the services they provide.
A settlement agreement with Martin’s Point described how the plan tried to game the risk-adjustment system by changing patient demographics and diagnoses to land higher payments from the Centers for Medicare & Medicaid Services. From 2016 to 2019, officials said, Martin’s Point engaged in chart reviews of its Medicare Advantage beneficiaries to identify additional diagnosis codes that had not been submitted to Medicare.
The company hired vendors and their own healthcare coders to pour through records, then add more diagnoses that could align with submissions. But the government, which got involved after a whistleblower revealed the strategy, said many of the additional codes were not properly supported by patients’ medical records.
While the Department of Justice did not respond to requests for information on the nature of patients being served, some of the commonly added codes represent diseases or conditions routinely found among nursing home residents. Among the codes added by Martin’s Point were diabetes with chronic complications, chronic obstructive pulmonary disease, congestive heart failure and vascular disease, according to the settlement.
In the decree, the government noted that Martin’s Point had made leadership and personnel changes since 2019. Its Medicare Advantage plans were rated 5 stars for 2023.
“It is a privilege for health plans to provide services to Medicare beneficiaries, not a right,” Christian J. Schrank, deputy inspector general for investigations at the Department of Health and Human Services, Office of Inspector, said in announcing the agreement Monday. “Medicare Advantage Plan sponsors that submit inaccurate claim information in order to justify inflated payments undermine the financial integrity of the program.”
The government said whistleblower Alicia Wilbur, a former manager in Martin’s Point’s Risk Adjustment Operations group, will receive about $3.8 million for originally filing a complaint and her subsequent role in the case.
