Reporting Medicare Advantage fraud (Medicare Part C Fraud)
If you properly report Medicare Advantage or Part C fraud, you may be entitled to a significant whistleblower reward. If you want former Justice Department Attorney Joel Hesch to evaluate in complete confidence to see if you have the right type of case to get a reward, then fill out the form at this link (click here) and Mr. Hesch will personally get back to you right away.
If you want to read more about the $1.75 billion in whistleblower reward cases Mr. Hesch has handled click here.
More Details about Medicare Advantage Fraud (Part C Fraud)
Medicare is in a financial crisis and risks going broke. One reason is because 10% of Medicare payments are lost to fraud, including those cheating or defrauding Medicare Advantage plans.
Medicare is asking you to report Medicare Advantage fraud, and the government is offering large whistleblower rewards as an incentive. But, to properly report Medicare Advantage plan fraud or receive a reward, you must strictly follow the correct procedures for reporting the Medicare Advantage fraud. If you don’t follow the reward program rules, you also might not best ensure that Medicare opens an investigation.
Here’s how to report Medicare Advantage fraud and how to apply for a whistleblower reward for reporting fraud under Medicare Advantage healthcare plans.
Medicare Advantage Plans: overview of potential fraud
Medicare allows people to choose between (1) the “fee-for-service” plan where they go to any doctor and Medicare pays the healthcare provider a set fee based on each healthcare service provided, and (2) Medicare Advantage plan, where Medicare pays private health plans a monthly fee for each Medicare recipient they enroll regardless of how many times they receive medical treatment. A common model using this type of a system is an HMO.
In an attempt to reduce fraud and more fairly pay Medicare Advantage plans their true costs for treating Medicare patients or Medicare recipients, Medicare came up with a complicated payment plan that pays different amounts to different Medicare Advantage plans. Medicare came up with a risk adjustment formula that pays more funds to Medicare Advantage plans that have a higher risk of treating Medicare patients that likely will need more healthcare services per month.
With respect to Medicare Advantage plans, Medicare makes a risk adjustment to determine the fee to pay for each Medicare recipient enrolled in a Medicare Advantage plan. Before Medicare began using risk assessments, many HMOs or Medicare Advantage plans tried to cheat or defraud the system by only enroll healthy people and discouraging or barring higher risk patients from joining, such as pregnant women or those with medical conditions. Today, the amount of payment to Medicare Advantage plans is adjusted based upon the health risks of those enrolled. However, Medicare Advantage has its own fraudulent schemes.
Prior to 2003, risk adjustment payments to the Medicare Advantage health plans were based on simple demographics, such as gender, age and zip code. Today, the risk adjustment is based on complex formulaic calculations, which means that there are plenty of opportunities for Medicare Advantage plans to cheat or defraud Medicare.
Examples of Medicare Advantage Fraud
There are many ways in which Medicare Advantage plans are cheating and defrauding Medicare. Anytime a Medicare Advantage plan provides risk-adjustment data to Medicare via the Centers for Medicare & Medicaid Services (CMS) that is inaccurate it is Medicare Advantage fraud. There are a host of other fraudulent schemes by Medicare Advantage plans, such as Upcoding fraud, Chart Review fraud, and Chart Mining fraud.
Coding guidelines applicable to Medicare Advantage plans requires at least the following three things: (1) billing only based upon face to face visits, (2) documentation must show how chronic condition is being treated, managed or assessed, and (3) each diagnosis must have an assessment and a plan. If any one is missing, it is Medicare Advantage plan fraud.
Upcoding fraud is a form of risk-adjustment fraud by Medicare Advantage plans because it exaggerates the severity of each of the Medicare Advantage plan members’ condition so that it appears that this Medicare Advantage plan should get an increased risk factor and more monthly payments. The Medicare Advantage plan fraudulently creates a higher risk score or larger risk multiplier in order to fraudulently increase the amount of the per member per month (pm/pm) capitation rate Medicare pays.
Chart review fraud is another form of risk-adjustment fraud by Medicare Advantage plans. Medicare requires that Medicare Advantage plans bill based upon face to face visits. When administrative people change or alter the bills or medical records or charts it is fraud because they were not based on a face to face visit by a healthcare provider. Is it also fraud because there is not documentation to show how the chronic condition is being treated or assessed, but was inputted based upon codes and rates to increase Medicare reimbursement.
There are many companies or outside vendors advertising to help conduct “chart audits,” “chart review services,” or “chart mining” and promise to help Medicare Advantage plans increase Medicare reimbursement. Unfortunately, many of these risk-adjustment data submission services (such as claims filtering) or chart review companies fraudulently upcode or only correct errors that increase payment and ignore or fail to correct errors that would decrease reimbursement. It is fraud when the Medicare Advantage plans change codes that are not based upon the healthcare providers’ face to face visits or fully documented to show how chronic conditions are being treated, managed or assessed and supported by an assessment and a plan.
It is also Medicare Advantage plan fraud to ask coders to adjust the codes based on other evidence in medical charts beyond the doctors’ documentation, such as based on what medications were prescribed or what laboratory test were order.
How much reward for reporting Medicare Advantage fraud?
The size of a whistleblower reward is calculated based on the size of the Medicare Advantage plan fraud. The reward is between 15 and 25 percent of the amount the government recovers back from the Medicare Advantage plan defrauding the Medicare. Recently, the government estimated that one Medicare Advantage plan in California by itself cheated or defrauded the government by $425 million. The government believes that this Medicare Advantage plan may have committed fraud because it based risk assessments that made patients seem sicker that they actually were, and may have committed fraud because it upcoded diagnosis such as claiming it was treating a patient for cancer when the Medicare patient did not have cancer.
If a whistleblower properly reports a large scale Medicare Advantage plan risk-adjustment fraud scheme and the government were to collect $425 million, the whistleblower reward would be between $63 million and $105 million.
Tips for reporting Medicare Advantage fraud and getting a reward
First, you can’t simply call a Medicare fraud hotline to report Medicare Advantage fraud to be eligible for a whistleblower reward. The only way how to get a reward for reporting Medicare Advantage fraud is hiring an attorney, which generally work on a contingency basis consisting of a percentage of any potential whistleblower reward, to file a qui tam suit under the False Claims Act. Your attorney must follow the exact process in the reward statute to be eligible for a reward for reporting the Medicare Advantage fraud. Therefore, it is key that you select an attorney experienced with handling reward applications for Medicare fraud cases.
In addition, you need to possess and report very specific information about the Medicare Advantage plan fraud. The government turns down 75% of all whistleblower reward applications, which highlights the need to hire an experienced attorney.
How to report Medicare Advantage plan fraud
This website (and the books authored by Mr. Hesch) walk you step-by-step through the process of reporting Medicare Advantage fraud and shows you how to report Medicare Advantage plan fraud and apply for a whistleblower reward.
Mr. Hesch has over 15 years of experience with investigating Medicare fraud against the federal government while working at the Civil Fraud Section of the U.S. Department of Justice in Washington, D.C. He now helps whistleblowers apply for rewards. Mr. Hesch is ready to review your information and show you whether and how to report Medicare Advantage plan fraud.
Click here to ask Attorney Hesch to review in complete confidence your potential Medicare Advantage plan fraud case and find out if you might be eligible for a reward for reporting Medicare Advantage plan (Part C) fraud.