Tags: Healthcare Reform | Medicare Advantage | overcharging | whistleblowers | lawsuits

Whistleblowers: Medicare Plans Overcharged Govt for Years

By    |   Thursday, 23 Apr 2015 12:15 PM

Whistleblowers and government investigators say privately run Medicare plans have overcharged the federal government for years, and at least a half-dozen lawsuits alleging abuses have been filed since 2010.

The lawsuits name insurers all over the country whose plans enroll millions of seniors, according to The Center for Public Integrity, and lawyers say even more cases should surface.

The Justice Department is investigating Medicare risk scores, the focus of the whistleblower suits. Medicare uses such scores to make higher payment rates for the more ill patients on its rolls and lower payments for those in good health, and officials have been getting warnings since 2009 that some of the private plans are claiming that patients were more ill than they really were to justify increasing payments.

More than 17 million members, or about a third of those eligible for Medicare, are signed up for privately run Medicare Advantage plans, which are favored by many seniors because of their low out-of-pocket costs. Health policy experts also argue that the plans can offer better care than standard Medicare, which pays providers on a fee-for-service basis.

But according to the whistleblower suits, it's easy for such health plans to price-gouge the government.

"It shows the incentives provided for whistleblowers are working well, and all the other controls and detection systems are failing miserably," Malcolm Sparrow, a healthcare fraud expert at Harvard's John F. Kennedy School of Government, said of the cases, which suggest government oversight of such programs may be lacking.

The Justice Department is also widening its investigation into whether the risk scores could be increasing Medicare costs.

On April 14, DaVita Healthcare Partners Inc. in Denver disclosed receiving a Justice Department subpoena, with investigators seeking its Medicare Advantage billing data.

And in another lawsuit, whistleblowers claim Blue Cross of South Carolina submitted inflated claims for four years, between 2006 and 2010. The lawsuit also names the Deseret Mutual Insurance Company, which had contracted with Blue Cross on the Medicare Advantage billings.

The lawsuit was filed by former Blue Cross computer billing specialist Catherine Brtva and former contractor Jerald Conte, and targets flaws in Blue Cross' computer systems used to submit health insurance claims to Medicare.

Blue Cross does not deny the overcharges, but also says underpayments happened.

Attorneys say they expect more cases to surface as the investigations continue.

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Whistleblowers and government investigators say privately run Medicare plans have overcharged the federal government for years, and at least a half-dozen lawsuits alleging abuses have been filed since 2010.
Medicare Advantage, overcharging, whistleblowers, lawsuits
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2015-15-23
Thursday, 23 Apr 2015 12:15 PM
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