In September, the U.S. Department of Health and Human Services’ Office of Inspector General issued a report raising concerns that some Medicare Advantage companies inappropriately used chart reviews and health risk assessments, or HRAs, to receive higher risk-adjusted payments. 

The OIG found that 20 of the country’s 162 MA companies accounted for a disproportionate share of $9.2 billion in payments from diagnoses that were only reported on chart reviews and HRAs. Of the 20 companies, one company stood out for having 40 percent of the risk-adjusted payments from both chart reviews and HRAs but enrolled only 22 percent of MA beneficiaries. The report did not name the companies. 

The OIG recommended that the Centers for Medicare & Medicaid Services provide oversight of the 20 companies, take additional actions to determine the appropriateness of payments and care for the one company that substantially drove risk-adjusted payments, and work to monitor and identify MA companies with a disproportionate share of risk-adjusted payments from chart reviews and HRAs. 

Whistleblowers play an important role in rooting out Medicare Advantage fraud, especially when it involves manipulation of risk-adjusted scores to obtain higher reimbursements for either the Medicare Advantage company or the healthcare provider who cares for the Medicare beneficiary. The False Claims Act incentivizes whistleblowers to report fraud on the government by rewarding them with a percentage of the amount the government recovers because of the whistleblower’s case. According to the Taxpayers Against Fraud Education Fund, between 2010 and 2020, the government’s FCA recoveries totaled $40.2 billion. Of that total, about 68 percent came from healthcare-related recoveries. 

In August, a Keller Grover client reached a record $90 million False Claims Act settlement with Sutter Health, a healthcare provider, to resolve her alleged claims that the health system submitted inaccurate and unsupported medical diagnosis codes, which inflated its Medicare Advantage reimbursements. We are here to help those who want to report wrongdoing. For advice about how to handle suspected fraud, contact Keller Grover for a free and confidential consultation. Over more than 30 years litigating fraud and employment cases, Keller Grover has recovered billions for its clients.