The
Department of Justice has sued Anthem, alleging that the health insurance
company knowingly submitted inaccurate medical codes to the federal government
from 2014 to 2018 as a way to get higher payments for its Medicare Advantage
plans and turned "a blind eye" to coding problems.
Why it
matters: This is one of the largest Medicare Advantage fraud lawsuits to
date, and federal prosecutors believe they have more than enough to evidence to
claim that Anthem bilked millions of dollars from taxpayers.
Background: DOJ has
been probing the
"risk adjustment" practices of all the major Medicare Advantage
insurers for years, but hadn't pulled the trigger on a lawsuit against a major
player.
·
Risk adjustment is the process by which Medicare Advantage
companies assign scores to their members based on the health conditions they
have. Patients who have higher risk scores lead to higher payments from the
federal government to the companies that insure them.
·
Insurers are required to review patients' medical charts to
verify the health conditions, and if insurers find any inaccurate diagnoses,
they have to be deleted — which also would require the companies to pay back
money to the federal government.
The
Department of Justice is alleging that Anthem reviewed medical records, but only
focused on finding "all possible new revenue-generating codes" while
purposefully ignoring all erroneous diagnoses.
·
For example, according to the DOJ's lawsuit, Anthem coded one
member in 2015 as having active lung cancer.
·
"Anthem’s chart review program did not substantiate the
active lung cancer diagnosis," the DOJ alleges. Instead of deleting that
diagnosis, Anthem allegedly added another three codes — leading to a $7,000
overpayment just for that member that year.
The other
side: Anthem said in a statement that it
intends "to vigorously defend our Medicare risk adjustment practices"
and that "the government is trying to hold Anthem and other Medicare
Advantage plans to payment standards that CMS does not apply to original
Medicare."
The big
picture: Medicare Advantage continues to enroll seniors
and people with disabilities at high rates, even as more allegations of fraud
come out against the insurers that run the program.
No comments:
Post a Comment