A Northern California health care provider is facing allegations by Federal prosecutors that it violated the False Claims Act by providing false information to Medicare beneficiaries in an effort at obtaining inflated payments from the government program.
Investigators say that the provider contracted with Medicare Advantage Organizations (MAOs) to offer services to area beneficiaries via their Medicare Advantage Plans (MA Plans), for which the firm was paid back a portion of the payments Medicare made to the MAOs.
The provider is also charged with submitting diagnoses to Medicare that did not match the conditions of the individuals for whose treatment they sought reimbursement. In the Medicare Advantage program (also known as Medicare Part C), the The Centers for Medicare and Medicaid Services (CMS) evaluates demographic and health information from each plan beneficiary and assigns each individual a risk score, with a higher payment allowed for patients with higher risk scores. Investigators say the provider submitted diagnosis codes unsupported by the patients’ actual health, increasing the risk scores and, as a result, increasing the risk-adjusted payment to the beneficiary. Federal investigators say the provider continued submitting such diagnosis codes even after being made aware of the practice’s existence.
The suit in question began as a whistleblower action, begun under the qui tam provisions of the False Claims Act (a/k/a “Lincoln’s Law”), which allows the Federal government to take over the action if, after investigating it, the government finds it meritorious.
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