Anthem faces a Justice Department lawsuit alleging Medicare Advantage insurer knowingly submitted inaccurate patient information to the federal government to allow it to fraudulently collect more than $100 million in payments. overpayment.
Judge Andrew L. Carter ruled in New York’s Southern District Court on Friday, rejecting Anthem’s offers to dismiss the case or relocate to a federal court in Ohio. The Justice Department sued Anthem in March 2020, alleging the insurer violated the False Claims Act by submitting inaccurate patient data as a way to obtain additional payments through Medicare Advantage plan.
Neither Anthem nor the Justice Department immediately responded to requests for interviews.
Health insurance companies are paid a flat fee to manage care for patients enrolled in Medicare Advantage. The Centers for Medicare and Medicaid Services determines that fee, in part, based on the number and severity of medical conditions the patient has. This payment method encourages Medicare Advantage insurers to capture as many patient conditions as possible through chart reviews, home health assessments, primary care visits, and more.
Between 2014 and 2018, Anthem aggregated the medical charts of Medicare Advantage members to find as many diagnostic codes as possible to submit to CMS, the lawsuit alleges. In the process, the insurer chose not to remove the thousands of incorrect diagnostic codes listed because it would reduce their revenue through the program, the lawsuit alleges.
“The financial costs to government here are substantial and not merely administrative costs,” Carter wrote in comments published Monday. He rejected Anthem’s offer to dismiss the case for lack of materiality.
The insurance company also argued that the case should be heard in federal court in Ohio because employees at its office in Columbus, Ohio, were accused of sending diagnostic codes to CMS. Carter ruled the case should be heard where the Anthem leaders are based.
“The location of the operational data for the purpose of this movement should be determined by the position of the decision makers. The facts point to a fraudulent scheme in which key decision-makers, namely Anthem executives, promoted a policy of revenue maximization rather than compliance with the law,” Carter wrote.
The Justice Department has sued other Medicare Advantage plans for allegedly charging more than the federal government for their services. But the main way health plans are held accountable through the program is through federal audits of their risk-adjusting practices, known as RADV audits. CMS said it plans to issue a series of audits from 2011 that will result in more than $600 million in overpayments being refunded by the end of the year.
The agency has also proposed changing the way these audits are conducted by removing comparisons of Medicare Advantage insurers with traditional Medicare, a technical change that would eliminate “cost adjusters”. service”. Health plans go against this rule, which can increase the amount owed by overpayments by $381 million annually. CMS is expected to release its long-awaited final rule, updating the measure in November.
