August 1, 2023
Medicare Advantage (MA) plan, Martin’s Point Health Care, Inc. in Portland Maine, has agreed to settle false claims act allegations with the DOJ, for approximately $22.5 million. This whistleblower case was brought on by a former manager of Martin’s Point’s Risk Adjustment Operations team, who will receive approximately $3.8 million.
The MA program allows private insurance companies (MA Plans) to contract with the Centers for Medicare & Medicaid Services (CMS) to provide Medicare beneficiaries healthcare coverage in exchange for reimbursement based on a capitated structure (fixed per member per month payments, regardless of how much or little services are provided to the beneficiary). The payments are calculated on the health “risk” of the beneficiary. The less healthy the beneficiary, with more chronic conditions/diagnoses, the higher the payment to the MA Plans.
Between 2016 to 2019, Martin’s Point retained vendors and employed healthcare coders to conduct chart reviews (evaluate medical records) to identify missed or unidentified diagnoses not previously submitted by healthcare providers. According to the Settlement, “Martin’s Point knowingly submitted additional diagnosis codes derived from Martin’s Points “chart review” program that were unsupported, unsubstantiated, and invalid based on the underlying medical records.”
Read the DOJ’s press release here.