The Department of Justice has asked health insurer Humana for more information about its Medicare Advantage risk-adjustment practices, based on a whistle-blower lawsuit from several years ago, Humana said last week in a regulatory filing.
The disclosure states that federal officials recently sent a request to Louisville, Ky.-based Humana requesting additional information about how it submits and manages risk-adjustment data for its Medicare Advantage beneficiaries. The CMS pays fixed monthly amounts to Advantage insurers such as Humana partially based on patient-risk scores, which indicate the severity of illness among a plan's members. Higher risk scores correlate to sicker patients and thus lead to higher payments to insurers.
That methodology has led to several whistle-blower lawsuits alleging Medicare fraud. The complaints, filed under the False Claims Act, have alleged that Medicare Advantage plans falsely inflate patient diagnoses to obtain higher payments from the government.
The DOJ'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 that Humana and one of its physician clinics knowingly submitted false claims to Medicare with bogus patient-risk scores.
The government is seeking to examine more of Humana's risk-adjustment data, including diagnoses from providers in that lawsuit, and to examine how the insurer monitors risk-adjustment compliance. No additional details were provided regarding the Justice Department's request, and Humana did not 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.