Medicare Advantage Fraud occurs when healthcare insurers knowingly abuse the Medicare Part C program in order to make money unlawfully. Many American seniors are increasingly choosing Medicare Advantage Plans (MA Plans) over traditional Medicare Part A (hospital), Part B (physician) and Part D (prescription) healthcare coverage. Under the Medicare Advantage program, healthcare insurers get a monthly capitated fee from Medicare/CMS, plus a monthly premium from the members, and the insurers are supposed to provide superior healthcare and wellness services to the plan members at a lower cost to the members and U.S. tax payers.
The capitated amount Medicare pays the MA Plan sponsor (usually an insurance company) is based on a given member’s Medicare Risk Adjustment (MRA) score. In other words, the sicker the person is the more the insurance company receives from Medicare/CMS. This simple equation has motivated unscrupulous healthcare insurers with Medicare Advantage Plans to “game” or inflate their members’ MRAs with diagnoses that make members look sicker than they really are. It also incentivizes the MA Plan sponsors to “cherry pick” healthy members and/or provide substandard healthcare services to members in order to save money improperly.
If you work in this field you may have felt at times you would like to report Part C Medicare Advantage Fraud. It is likely you’ve seen an MA Plan sponsor implement one way audit programs which seek to add supposedly overlooked negative diagnoses to ramp up MRA scores, while not looking to uncover mistaken diagnoses that caused MRAs to be artificially high. Sometimes patient medical charts may even have been fabricated with outright bogus diagnoses. Maybe you are also aware of plan member recruitment tactics designed to bring in healthier members and keep out sicker ones. And it is possible you’ve seen systemic practices where a Medicare Advantage Plan sponsor tries to save money by failing to arrange for its members to receive the level of healthcare services they need. It’s conceivable you alerted a MA Plan sponsor about specific instances where any of these or similar practices have occurred and your concerns have fallen on deaf ears. It can be extremely disheartening. There is, however, an alternative way of trying to end MA Plan fraud.
If you have observed anyconduct you believe is improper and would like to report Medicare Advantage Fraud and help stop it, your best course of action may be to contact an experienced qui tam whistleblower attorney who can help guide you, assess your rights, contact the Government to report the fraud and even file a federal qui tam whistleblower lawsuit on your behalf. Many attorneys in this field will not charge you for a consultation and any communications you have with them will be privileged and confidential.
It is always best to begin this dialogue as soon as possible, especially if you still have access to evidence that can corroborate your allegations.
