Last week, the U.S. Department of Justice (DOJ) announced a $22.4 million settlement resolving allegations that Martin’s Point Health Care, Inc. (Martin’s Point) violated the False Claims Act (FCA) by submitting inaccurate diagnosis codes for its Medicare Advantage Plan enrollees.
The settlement derived from a qui tam suit brought by a former Martin’s Point employee. See United States ex rel. Wilbur v. Martin’s Point Health Care Inc.,No. 2:18-cv-00254 (D. Me.). As part of the resolution, the relator will receive $3,822,450 of the settlement amount.
According to the government, for payment years 2016 to 2019, Martin’s Point operated a “chart review” program, in which it retained vendors (including DxID, a defendant in United States ex rel. Teresa Ross v. Independent Health Corp., No. 1:12-cv-00299 (W.D.N.Y.)) to review medical records and identify and add additional risk-adjusting diagnosis codes that were not previously documented. Martin’s Point then allegedly submitted these diagnosis codes to the Centers for Medicare & Medicaid Services (CMS) to obtain increased reimbursements. The alleged conduct focused on coding historical but no longer active conditions, and the submitted codes mapped to the following hierarchical condition categories (HCCs): 18 (diabetes with chronic complications), 19 (diabetes without complications), 22 (morbid obesity), 40 (rheumatoid arthritis and inflammatory connective tissue disease), 55 (drug/alcohol dependence), 85 (congestive heart failure), 88 (angina pectoris), 96 (specified heart arrhythmias), 108 (vascular disease), and 111 (chronic obstructive pulmonary disease).
The complaint further alleged that in 2017, Martin’s Point retroactively reviewed a sample of diagnosis codes submitted from 2013 to 2015 and found that the patients did not have (or the records did not support) 60% of the illnesses reported to and paid by CMS. Martin’s Point allegedly did not appropriately respond to this finding, including by failing to delete the unsupported codes. The complaint also alleged that Martin’s Point exerted pressure on its employees and contractors to document unsupported risk-adjusting diagnosis codes, including by setting risk-score targets, directing employees and contractors to ignore unsupported codes, and providing monetary incentives to providers to complete forms aimed at increasing the number of HCCs per patient.
The settlement “sends a clear message to the Medicare Advantage community that the United States will take appropriate action against those who knowingly submit inflated claims for reimbursement,” said Deputy Assistant Attorney General Michael D. Granston of DOJ’s Civil Division’s Commercial Litigation Branch in the agency’s press release.
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