A federal appeals court resurrected a whistle-blower case against UnitedHealthcare, Aetna and healthcare companies for allegedly submitting false data for Medicare Advantage payments.
Whistle-blower James Swoben accused the companies of conducting biased retrospective medical record reviews to certify their risk adjustment data for Medicare Advantage submissions, and the Ninth Circuit determined he should get another chance to flesh out his lawsuit.
According to the suit, UnitedHealthcare, Aetna, WellPoint and Health Net and the physician group HealthCare Partners all submitted false diagnosis codes starting in 2005 to secure higher Medicare Advantage payments. The companies used coding companies or software to perform necessary retrospective reviews to certify their data, but they left out the relevant codes.
Medicare Advantage participants are required to certify their data to CMS because they could financially benefit from submitting erroneous codes. Swoden alleged the companies were already on notice that their data was suspect, as CMS had told them their data likely included a number of erroneous codes.
Although a lower court threw out Swoben's case, saying a fourth amended complaint would be “futile,” the Ninth Circuit said his proposed changes were enough to warrant the request.
Swoben, a former data encounter manager at SCAN Health Plan, has also been involved in another whistleblower case that ended in a $320 million settlement between the government and his former employer. Although whistleblowers typically get 15 to 30% of awards and settlements stemming from their accusations, Swoben was cut out of SCAN windfall because a federal judge determined he was not the original source of the information contained in the lawsuit.
Now, Swoben will have another chance at the insurers and physician group, and the Ninth Circuit also awarded him costs for the appeal.