We've had some major news stories about Medicare Advantage Plans overcharging lately. What exactly are they about?
In May, we heard about a couple of Florida MAPD insurers that agreed to pay almost $32 million to settle a lawsuit that said they made patients seem sicker than they really were so that they could get larger payments from Medicare.
Dr. Darren Sewell filed the lawsuit in 2009. He actually worked at both plans, Freedom Health and Optimum HealthCare. These plans were both based in Florida and Dr. Sewell worked for them from 2007 to 2012.
Sadly, he died in 2014, but his family took over the case.
Dr. Sewell claimed that the plans made patients seem sicker than they really were. He said that they claimed that these patients had …show more content…
At least six whistle-blowers have sued health plans because they said that the plans attempted to boost their profits by tampering with the risk scores. Among the first to settle was The Sewell.
Sewell's attorney, Mary Inman said, "This is the largest whistle blower settlement involving health insurers' manipulation of their members' risk scores," said She also said that it "...sends an important signal to health insurers that the government is serious about risk adjustment fraud."
In a statement, Freedom and Optimum corporate counsel Bijal Patel denied any wrongdoing.
"Although Medicare managed care is a complex and constantly changing industry in which it is common to have differing interpretations of regulations, with this settlement, we have agreed to resolve disputed claims without any admission of liability in order to avoid delay and the expense of litigation, so that we can focus on providing quality care, member service and maintaining the highest Medicare Star Ratings," Patel …show more content…
This is also a violation of Medicare regulations.
The suit also alleged that these two health plans directed their doctors to call their patients to have them come in for unnecessary office visits, with the idea to find ways to raise their risk scores so the plans would get larger capitated payments.
The Optimum plan originally it had about 3,000 members when it started in 2004 but later expanded. Freedom also began as a small plan in 2005, but it grew to over 12,000 just two years later.
These health plan officials allegedly directed their employees to look for new billing codes that could be added to their patients and submitted to Medicare.
But according to the lawsuit, both Freedom and Optimum knew that up to 80 percent of the added codes were unsubstantiated.
According to the suit, these actions resulted in more than $40 million in Medicare overpayments during 2009 and 2010, Freedom Health and Optimum HealthCare will pay $16.7 million for the allegations of risk adjustment fraud and $15 million for the allegations of improper expansion of their
In May, we heard about a couple of Florida MAPD insurers that agreed to pay almost $32 million to settle a lawsuit that said they made patients seem sicker than they really were so that they could get larger payments from Medicare.
Dr. Darren Sewell filed the lawsuit in 2009. He actually worked at both plans, Freedom Health and Optimum HealthCare. These plans were both based in Florida and Dr. Sewell worked for them from 2007 to 2012.
Sadly, he died in 2014, but his family took over the case.
Dr. Sewell claimed that the plans made patients seem sicker than they really were. He said that they claimed that these patients had …show more content…
At least six whistle-blowers have sued health plans because they said that the plans attempted to boost their profits by tampering with the risk scores. Among the first to settle was The Sewell.
Sewell's attorney, Mary Inman said, "This is the largest whistle blower settlement involving health insurers' manipulation of their members' risk scores," said She also said that it "...sends an important signal to health insurers that the government is serious about risk adjustment fraud."
In a statement, Freedom and Optimum corporate counsel Bijal Patel denied any wrongdoing.
"Although Medicare managed care is a complex and constantly changing industry in which it is common to have differing interpretations of regulations, with this settlement, we have agreed to resolve disputed claims without any admission of liability in order to avoid delay and the expense of litigation, so that we can focus on providing quality care, member service and maintaining the highest Medicare Star Ratings," Patel …show more content…
This is also a violation of Medicare regulations.
The suit also alleged that these two health plans directed their doctors to call their patients to have them come in for unnecessary office visits, with the idea to find ways to raise their risk scores so the plans would get larger capitated payments.
The Optimum plan originally it had about 3,000 members when it started in 2004 but later expanded. Freedom also began as a small plan in 2005, but it grew to over 12,000 just two years later.
These health plan officials allegedly directed their employees to look for new billing codes that could be added to their patients and submitted to Medicare.
But according to the lawsuit, both Freedom and Optimum knew that up to 80 percent of the added codes were unsubstantiated.
According to the suit, these actions resulted in more than $40 million in Medicare overpayments during 2009 and 2010, Freedom Health and Optimum HealthCare will pay $16.7 million for the allegations of risk adjustment fraud and $15 million for the allegations of improper expansion of their