Qui tam attorney Eva Gunasekera explains Medicare Advantage fraud and how to report it. The False Claims Act enables whistleblowers to file a claim against an entity involved in a Medicare Advantage or Medicare Part C fraud.
Watch the video or read the transcript below.
Speaker: Tycko & Zavareei LLP Partner Eva Gunasekera
Medicare Advantage is a managed care program that allows the Medicare recipient to choose a private insurance company. It is also known as Part C. Part C provides an alternative to the traditional fee for service program and pays a capitated amount to private insurers for each patient, adjusting the payments for health risk factors.
How Does Medicare Advantage Fraud Happen?
The sicker a patient, the more money Medicare Advantage pays for that patient. While intended to save money, certain players in the healthcare industry have caused Medicare Advantage to lose money. When that happens, the Department of Justice uses the False Claims Act to get its money back. DOJ is interested in hearing from you if you work for any entity that participates in Medicare Advantage. Whether it’s an insurance company or a Medicare Advantage Organization (otherwise known as an MAO), one of the thousands of health care providers contracted with the MAOs, or a vendor servicing the MAOs and the Medicare Advantage patients.
How Do You Know If You Have a False Claims Act Case?
You may have a False Claims Act case if your employer is doing any of the following: manipulating the risk adjustment process, submitting or using unsupported diagnosis codes to make patients appear sicker than they are, submitting or using inaccurate information about the health services provided for those patients, or doing anything to knowingly increase payments for Medicare Advantage patients in violation of the rules.
Do You Have Information About Medicare Advantage Fraud? Contact a Whistleblower Lawyer
If your case is successful, there are financial rewards for whistleblowers under the False Claims Act, and there are protections against retaliation for raising your concerns to your employer or the government. Please visit us at fraud fighters.net.