A whistleblower’s qui tam case against a Medicare Advantage Organization (MAO) alleging fraudulent retrospective chart review practices has been permitted to proceed, according to a recent ruling by the U.S. District Court for the Western District of New York. The ruling in United States ex rel. Teresa Ross v. Independent Health Corporation, DxID LLC, et al. is significant because it allows the case to move forward despite the MAO’s attempt to have it dismissed on procedural grounds. This type of fraud perpetrated by MAOs – which are private entities that contract with Medicare to provide health care benefits to seniors and other enrollees – is estimated to cost taxpayers billions of dollars each year. If successful, this qui tam action could help recoup some of those losses and send a powerful message that such fraud will not be tolerated. This blog previously reported on this case in 2021.
A former employee of the MAO, referred to as a qui tam relator, has alleged that Independent Health engaged in retrospective chart reviews, adding unsupported diagnosis codes to receive inflated payments from Medicare. Submitting false diagnoses to receive excess payment under the Medicare Advantage program (also known as Part C) is a violation of the False Claims Act.
The legal case between the government and the defendants had been a contentious one, with both sides firmly standing by their arguments. The government argued that the coding provision of the International Classifications of Diseases guidelines required documentation showing that the physician had treated the condition during that particular encounter or showed how it had impacted care in some way. However, the defendants maintained that all they had to do was document that there was a condition present and nothing more was required. The court found that the government had shown enough evidence to allege a violation of a legal obligation and thus rejected the MAO and subsidiary’s motion for dismissal. As such, this decision has major implications for similar legal cases alleging Medicare Advantage fraud based on retrospective chart reviews.
Whistleblowers are essential for uncovering fraud, and the Medicare Advantage program is no exception. Those who wish to bring qui tam cases alleging Medicare Advantage fraud have a powerful tool in the False Claims Act at their disposal, but it is vital they make the right decision. The Medicare Advantage program relies heavily on public funds, so holding recipients of those funds accountable to the highest standards is of vital importance. Whistleblowers play an integral role in this process and should arm themselves with the latest information to effectively spot and report Medicare Advantage fraud.
The court’s decision allows the government’s intervention in this case to proceed against organizations that engage in fraudulent chart reviews. If you have information about similar False Claims Act violations, contact the whistleblower attorneys at Tycko & Zavareei LLP. Eva Gunasekera and Renée Brooker are former officials of the United States Department of Justice and prosecuted whistleblower cases under the False Claims Act. Eva was the Senior Counsel for Health Care Fraud. Renée served as Assistant Director at the United States Department of Justice, the office that supervises False Claims Act cases in all 94 United States District Courts. Eva and Renée now represent whistleblowers. For a free consultation, you can contact Eva Gunasekera at [email protected] or contact Renée at [email protected] (tel.: 202-417-3664). Visit Tycko & Zavareei LLP’s website for whistleblowers to learn more at https://www.fraudfighters.net/.