The U.S. Justice Department has asked health insurer Humana for information related to its Medicare Advantage risk-adjustment practices, building off a whistle-blower case from several years ago, Humana said in a regulatory filing late Wednesday.
The disclosure states that federal officials "recently" sent a request to Louisville, Ky.-based Humana asking for more information about how it submits and manages risk-adjustment data for Medicare Advantage beneficiaries. The CMS pays fixed monthly amounts to Medicare Advantage insurers like Humana partially based on risk scores, which indicate how sick members are. Higher risk scores correlate to sicker patients and thus lead to higher payments to insurers.
That methodology has led to whistle-blower lawsuits alleging Medicare fraud. The complaints, filed under the False Claims Act, accuse Medicare Advantage plans of falsely inflating patient diagnoses to obtain higher payments from the government.
The Justice Department's request is "separate from but related to" a whistle-blower lawsuit that was filed several years ago, Humana said. That lawsuit, filed by Dr. Olivia Graves in 2010, alleged Humana and one of its physician clinics knowingly submitted false claims to Medicare with bogus patient risk scores.
The government is seeking to find out more about Humana's risk-adjustment data, including diagnoses from providers in that lawsuit, and how the insurer monitors risk-adjustment compliance. No additional details were provided regarding the Justice Department's request, and Humana did not immediately respond to a request for comment.
"We continue to operate with and voluntarily respond to the information requests from the Department of Justice and the U.S. attorney's office," Humana said in the filing.
Humana is the second-largest Medicare Advantage insurer in the country with almost 3.2 million members, according to February 2015 data from the CMS.
Follow Bob Herman on Twitter: @MHbherman
