Feds Join Medicare Advantage Coding Lawsuits Against Kaiser


The Justice Department said Friday that the federal government intervened in six lawsuits alleging that Kaiser Permanente changed its Medicare Advantage claim code.

The Integrated Health System in Oakland, California, allegedly forced its doctors to supplement medical records, often several months after assistance, in order to increase Medicare reimbursement. Doctors added risk-adjusted diagnoses that were not or were not considered in patients, the lawsuits allege.

“The federal government pays hundreds of billions of dollars annually to Medicare Advantage plans,” said Matt Kirsch, acting US attorney for the District of Colorado. prepared comments… “The District of Colorado will vigorously investigate with our partners to make sure the money is supporting essential healthcare and not fraud.”

Kaiser expressed confidence that the company is MA compliant and will defend itself against lawsuits alleging otherwise, noting nearly a decade of “excellence” in CMS risk adjustment audits.

“Our medical records and risk adjustment diagnosis data submitted to Medicare and Medicaid Service Centers comply with applicable laws and Medicare Advantage requirements. Our policies and practices represent reasoned and fair interpretations of the sometimes vague and incomplete CMS guidelines. “, – said in the message of the organization.


Whistleblowers file qui tam lawsuits on behalf of the government, which can intervene, allow the whistleblower to assert claims and observe the trial, or proceed to rejection. He interferes with less than 25% cases of violations. Typically, the government only intervenes when there is a high probability of success and a potentially major settlement, legal experts say.

Federal authorities have launched several investigations into coding in the master’s program, which continues to grow rapidly. For example, Freedom Health and Optimum Healthcare agreed to pay $ 31.7 million in 2017 to pay for MA-related upgrades. The Office of the Inspector General of HHS released a report in April claiming that Humana inflated CMS fees by nearly $ 200 million for false or inflated claims.

MA reimbursement is based on regional trends and usage in traditional Pay-for-Service Medicare, and adjustments to plan members’ risk assessments. Someone with a chronic condition has a higher risk score and the government will pay more to a private health plan that covers an MA recipient.

Risk assessments were intended to stimulate plans to reach all older people, not just the healthier. But a number of recent whistleblower lawsuits allege unnecessary codes were added to health plans or otherwise inflated points to get more money.

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