More whistleblowers allege health plan overcharges
Cases target Medicare Advantage billing practices
by Fred Schulte
Center for Public Integrity, April 23, 2015
Privately run Medicare plans, fresh off a major lobbying victory that reversed proposed budget cuts, face new scrutiny from government investigators and “whistleblowers” who allege plans have overcharged the government for years.
Federal court records show at least a half dozen whistleblower lawsuits alleging billing abuses in these Medicare Advantage plans have been filed under the False Claims Act since 2010, including two that just recently surfaced. The suits have named insurers from Columbia, S.C., to Salt Lake City, Utah to Seattle and plans which have together enrolled millions of seniors; lawyers predict more whistleblower cases will surface. The Justice Department also is investigating Medicare risk scores.
Though specific allegations vary, the whistleblower suits all take aim at these risk scores. Medicare uses the scores to pay higher rates for sicker patients and less for people in good health. But officials were warned as early as 2009 that some plans claim patients are sicker than they actually are to boost their payments.
Privately run Medicare Advantage plans have signed up more than 17 million members, about a third of people eligible for Medicare, and are poised to get bigger. Their lobbying muscle is keeping pace with that growth. Earlier this month, the industry overturned proposed cuts sought by the Obama administration for a third straight year, instead winning a modest raise in payment rates for the programs.