Jan 27

Report Medicare Advantage Risk-Adjustment fraud under Medicare Part C and receive a whistleblower reward

This article shows you how to receive a whistleblower reward for reporting Medicare Advantage fraud (or risk-adjustment fraud) under Medicare Part C.

Health care companies that sponsor or provide Medicare Advantage and PACE plans often develop schemes to cheat Medicare by millions of dollars a year. The government is offering significant monetary rewards to whistleblowers who work for the company and expose their fraud schemes. Learn how to detect the fraud and how to apply for a reward.

Medicare Advantage Program Fraud

Medicare Part C or Medicare Advantage is the managed care version of Medicare. The government (CMS) awards Part C contracts to private insurance carriers to administrate Part C or Medicare Advantage plans (including PACE plans). Based upon the number of patients and the severity of illnesses for the covered population, CMS pays the insurance carrier a pre-set rate often referred to as a monthly capitation fee.

CMS uses risk scores to determine how much a carrier or sponsor is paid for each member of a plan. Risk scores assign a value based on the services expected to be provided to those included in the plan. For instance, an individual whose family has a history of heart attacks or a prior illness would have a higher risk score than an identical individual without a family history. The higher the risk score of plan members, the more the company is paid for that member’s plan.

CMS pays the carrier or plan sponsor an amount based solely on the number of members enrolled at each risk score, and not the actual services received by the beneficiaries. Because payment is based on risk score, carriers are tempted to artificially create a higher risk score.

Examples of risk score fraud under Medicare Advantage Program or PACE plans

Carriers or plan sponsors use a variety of schemes to defraud Medicare Part C. Here are some of the common schemes.

  • Upcoding diagnoses to exaggerate the severity of the condition (i.e. claiming that they are sicker than they are) in order to inflate the risk score and increase the capitation rate
  • Using “chart audits” or “chart reviews” or “chart mining” to find places to add diagnosis or upcode diagnosis, i.e. an administrator changes or adds codes to patient files instead of based upon medical doctors merely to increase the risk score
  • Giving employees bonuses or other incentives to upcode
  • Telling coders to go beyond the doctor’s documented diagnoses and add other diagnoses based on reading the medical charts (i.e. if a patient took a certain medications or test, add a diagnosis that often goes with such medication despite the fact that this patient did not have such illness)
  • Conducting a mock risk adjustment data validation (RADV) audit – and failing to submit to CMS any delete codes or errors spotted.

If you know of one of these schemes, you should talk to an experienced whistleblower reward attorney to find out how to apply for a reward for reporting fraud.

The DOJ Whistleblower Reward Program

Under the False Claims Act (FCA), the Department of Justice (DOJ) pays rewards of up to 30% of the money it recovers back from a company submitting false claims. This includes reporting Medicare Advantage fraud (or risk-adjustment fraud) under Medicare Part C.

To be eligible for a reward, you must hire an attorney and file a whistleblower complaint against the company. The case is initially filed under seal in order to give the government time to investigate the allegations without tipping off the defendant. The government then has an opportunity to take over the case or allow the whistleblower through their attorney to proceed alone to recover back the improper payments. The government pays the whistleblower a portion of the amount actually recovered, consisting of 15% to 25% in cases DOJ takes the lead and 25% to 30% if the whistleblower’s attorney controls the case. For example, if the case settles for $100 million, the whistleblower could receive between $15 million and $30 million depending on certain factors.

Report Medicare Advantage fraud to your attorney and the government

You should carefully select your False Claims Act whistleblower reward attorney. During the process of considering reporting fraud, you can contact an attorney in confidence prior to deciding whether to report fraud. Even before you sign a representation agreement with an attorney, by law and legal ethic duties, your communications with an attorney while in the process of selecting an attorney are protected by the attorney client privilege. That means that your attorney must keep your information confidential and cannot disclose it to anyone without your express approval, even if you decide not to hire that law firm.

How to ask The Hesch Firm to become your whistleblower reward attorney

Mr. Hesch would be pleased to review in complete confidence your allegations of fraud against the government. He will determine in strict confidence if he believes you have a case where a significant reward is possible and can discuss the risks and rewards with you before you decide to report Medicare Advantage fraud. You can read his extensive experience as an attorney working for the Civil Fraud Section of the U.S. Department of Justice (DOJ) in the whistleblower reward office on this website. Not only did Mr. Hesch work for more than 15 years in the Washington, D.C. DOJ office that pays nation-wide whistleblower rewards, but for the past 10 years he has represented clients, including doctors, nurses, auditors, managers and many other types of employees report their company for committing fraud. He has even worked on Medicare Advantage fraud cases under Part C and can help you decide whether to file for a reward.

See the link at the bottom of this web-page below “Do I have a case” to have Mr. Hesch review your potential whistleblower reward case and help you decide whether to report fraud and file for a whistleblower reward.

(Disclaimer: This article is for information only and should not be viewed as legal advice. Each case is unique and you should speak to an experienced whistleblower reward attorney about your situation.)

Find out if Mr. Hesch (and the team of attorneys that works with him) is the right whistleblower reward firm for you in reporting Medicare Advantage fraud or PACE plan fraud under Medicare Part C.

  1. Anonymous 21 Apr 2017 | reply

    Private companies that provide healthcare insurance to Medicare beneficiaries may violate the False Claims Act by knowingly submitting claims to the government for more risk adjustment reimbursement than is warranted by plan enrollees health status.

Leave a Comment

reset all fields