A California health care provider and one of its doctors have agreed to pay over $5 million to settle claims by the Federal government that it submitted false claims to Medicare.
Federal prosecutors say the California firm contracted with several area Medicare Advantage Organizations (MAO) to provide its enrollees with health care services in exchange for a share of the payments it receives from Medicare. As Medicare pays MAOs more for patients with more severe diagnoses, investigators say the firm took advantage of the fact by submitting additional diagnosis codes that did not match the patients’ actual health to the MAOs.
According to investigators, the doctor in question knowingly submitted false codes to the MAOs in order to receive inflated payments on behalf of the health care provider and with the health care provider’s full knowledge. The Federal government became aware of the alleged fraud as a result of a claim brought under the whistleblower (or qui tam) provisions of the False Claims Act (a/k/a “Lincoln’s Law”), allowing a whistleblower to file suit and turn the suit over to the Federal government if it finds merit in the claims.
The health care provider agreed to pay to the Federal government a payment of $5,039,180 to resolve the claims against it without going to trial.
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