The settlement announced October 1 resolves DaVita from False Claims Act liability for providing inaccurate information that caused Medicare Advantage plans to receive inflated Medicare payments.
DaVita voluntarily disclosed to the feds practices instituted by HealthCare Partners, a large California-based independent physician association DaVita acquired in 2012. Based on these self-disclosures, and DaVita’s cooperation with the government’s subsequent investigation, the United States agreed to a favorable resolution of potential claims arising from the conduct.
DaVita disclosed that practices at HealthCare Partners resulted in MA plans submitting incorrect diagnosis codes to CMS and obtaining inflated payments in which DaVita and HealthCare Partners shared. As an example, HealthCare Partners disseminated improper medical coding guidance instructing its physicians to use an improper diagnosis code for a particular spinal condition that yielded increased reimbursement from CMS.
The U.S. Attorney said the settlement also resolves allegations made by a whistleblower that HealthCare Partners engaged in “one-way” chart reviews – scouring patients’ medical records for diagnoses its providers may have failed to record. HealthCare Partners then submitted “missed” diagnoses to MA plans to obtain increased Medicare payments from CMS. In addition, the DOJ said HealthCare Partners also ignored inaccurate diagnosis codes that should have been deleted and that would have decreased Medicare reimbursement or required the MA plans to repay money to Medicare.
U.S. Attorney Nick Hanna,
This case involved illegal conduct in which patients’ medical conditions were improperly reported and were not corrected after further review – all for the purpose of boosting the bottom line. We will continue to pursue and hold accountable any entity that seeks to illegally increase revenue at the expense of the Medicare Advantage so that the program may continue to remain viable for all who need it.
The allegations of “one way” chart reviews were brought in a lawsuit under whistleblower provisions of the Federal False Claims Act. The whistleblower was James Swoben, a former employee of a MA plan that did business with DaVita. Mr. Swoben will receive nearly $10.2 million for the settlement of the “one way” allegations. The whistleblower provisions allows private parties to sue on behalf of the government for false claims and to receive a share of any recovery.
MA plans are paid fixed, monthly amounts to provide healthcare to Medicare beneficiaries who enroll in their plans. Medicare payments to MA plans are “risk adjusted” to reflect, in significant part, the health status of the beneficiary. The result is that MAO plans receive higher payments for patients who are diagnosed with conditions that require greater care.
DaVita operated an Medicare Service Organization and contracted with MA plans in various states, including California, Nevada, and Florida. In connection with the medical services it provided to those beneficiaries, DaVita collected and submitted diagnoses to the MA plans. As payment for its services, DaVita received from the plans a share of the payments received from CMS for the beneficiaries under DaVita’s care, said the Department of Justice.
Read the story from the Los Angeles Business Journal
Read the press release from The U.S. Department of Justice
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