DOJ's Medicare Advantage lawsuits, investigations likely to change insurance culture
Skip to main content
MDHC_Logotype_white
Subscribe
  • My Account
  • Login
  • Subscribe
  • News
    • This Week's News
    • COVID-19
    • Providers
    • Insurance
    • Government
    • Finance
    • Technology
    • Safety & Quality
    • People
    • Regional News
    • Digital Edition
    • Digital health funding hit $7.2B in Q1
      HHS allocates $145 million to health center look-alikes to fight COVID-19
      The Check Up: Kevin Shimamoto
      The Check Up: Kevin Shimamoto of Valley Children's Hospital
      Covid_unit_Beaumont_Dearborn-main_i.jpg
      ER doctors 'manage chaos' amid COVID-19 surge in Michigan
    • HHS allocates $145 million to health center look-alikes to fight COVID-19
      The Check Up: Kevin Shimamoto
      The Check Up: Kevin Shimamoto of Valley Children's Hospital
      Covid_unit_Beaumont_Dearborn-main_i.jpg
      ER doctors 'manage chaos' amid COVID-19 surge in Michigan
      Pandemic propels medical supply companies
    • Some healthcare associations moving full steam ahead with conferences starting in summer
      COVID hospitalizations in Michigan top fall surge; Beaumont seeing nurse 'burnout'
      Calls mount for Biden to track U.S. healthcare worker deaths from COVID
      Front-line workers want more assistance after a year of COVID-19
    • BlueCrossBlueShield_06_03_07_0.jpg
      Blue Cross bosses pocket pay hikes
      UnitedHealthcare sees Q1 profits rise and other key earnings takeaways
      California re-opens enrollment for health insurance coverage
      Insurers are partnering to offload the costs of kidney failure patients
    • HHS allocates $145 million to health center look-alikes to fight COVID-19
      Biden admin throws out Texas Medicaid waiver
      J&J vaccine pause a minor blip, but efforts must press on, experts say
      Effort to keep Arkansas Medicaid plan falls short in state Legislature
    • Private equity's estimated healthcare spending halved in first quarter
      UH reports $54.7M operating income for 2020 despite significant COVID-related costs
      CMS issues new guidance to enforce price transparency rule
      Massachusetts to crack down on highest-cost hospitals, insurers
    • Digital health funding hit $7.2B in Q1
      The Check Up: Kevin Shimamoto
      The Check Up: Kevin Shimamoto of Valley Children's Hospital
      Bright Health scoops up telehealth startup
      FCC to open next round of COVID-19 telehealth program applications
    • Michigan expands antibody treatment to cut hospitalizations
      J&J vaccine pause a minor blip, but efforts must press on, experts say
      A year into pandemic, federal officials design new mask guidelines to better protect more workers
      FDA pauses enforcement of in-person dispensing requirement for abortion pill
    • Oscar names new virtual-first care division president
      Redfield joins Big Ass Fans, which promotes controversial COVID-killing technology
      Next Up Podcast: Modern Healthcare's editor Aurora Aguilar talks new content direction
      Novant Health adds chief payor performance officer
    • Midwest
    • Northeast
    • South
    • West
  • Insights
    • ACA 10 Years After
    • Best Practices
    • Special Reports
    • Innovations
    • The Affordable Care Act after 10 years
    • A close-up of a woman receiving a COVID-19 vaccine.
      Providers in underserved communities work toward equitable vaccine distribution
      Josh Bradshaw
      How one rural Illinois county vaccinated 84% of its senior citizens by early March
      Dr. John Fischer
      Patient-reported outcomes tool for hernia surgery helps physicians improve care
      New care model helps primary-care practices treat obesity
    • Jennifer Pannone and her daughter Victoria.
      Mental health access for children needs attention
      A family photo of the the Hangens.
      Stressing the already burdened pediatric behavioral health system
      What's next for on-demand telehealth companies?
      A CalOptima PACE vaccination clinic.
      Will COVID-19 be the catalyst for creating a more sustainable healthcare system?
    • Ryan McGinnis
      Finding efficiencies in the OR using tech
      Dr. Daniel Hall
      UPMC pilots machine learning, telehealth to inform patient transfers
      A woman being recorded using her inhaler on a smartphone.
      Digital check-ins, connected inhalers help control asthma
      A phone screen showing the question, "Mary we hope this information was helpful and we'd like to keep guiding you. Are you interested in knowing when it's your turn to receive the vaccine?"
      Chatbots, texting campaigns help manage influx of COVID vax questions
  • Transformation
    • Patients
    • Operations
    • Care Delivery
    • Payment
    • Mayo Clinic launches two tech companies
      Diabetes patients at high risk for COVID-19 are managing conditions more effectively
      Nearly 1 in 5 Americans skipped care due to cost last year
      COVID-19 long-haulers need holistic treatment, providers say
    • Amazon gives out $12M under next phase of AWS diagnostics development initiative
      Malpractice premiums peak in 2020, AMA survey shows
      A rendering of a cancer research institute at the University of Southern California that will include 5G.
      Healthcare providers determine how to best use ultrafast 5G
      Two-thirds of largest hospitals aren't complying with price transparency rule
    • Hospitals face specialty pharmacy challenges with insurer competition
      Addressing long-standing barriers needed for mental and physical health integration
      A close-up of a woman receiving a COVID-19 vaccine.
      Providers in underserved communities work toward equitable vaccine distribution
      The waiting room of a Kaiser Permanente clinic at a Target location.
      Health systems revamp their approach to retail clinics
    • Payers, providers clash over telehealth reimbursement as Congress mulls changes
      When money talks. Why cash pay is becoming more popular
      CMS wants to bump pay for hospices, SNFs next year
      CMMI pauses new Direct Contracting model applications
  • Data/Lists
    • Rankings/Lists
    • Interactive Databases
    • Data Points
    • Health Systems Financials
      Executive Compensation
      Physician Compensation
  • Op-Ed
    • Bold Moves
    • Breaking Bias
    • Commentaries
    • Letters
    • Vital Signs Blog
    • From the Editor
    • Dr. Alan Kaplan
      The risks, rewards of taking organizations 'where they haven’t gone before'
      Wellstar CEO calls adapting for the pandemic her bold move
      Howard P. Kern
      Recognizing the value of telehealth in its infancy
      Dr. Stephen Markovich
      A bold move helped take him from family doctor to OhioHealth CEO
    • Drs. Hal Paz and Joshua J. Joseph
      Mobilized to fight the COVID crisis: a blueprint for community and academic partnerships
      Dr. Stephen Markovich
      Making sure we're aligned along the path to achieving inclusion
      Barry Ostrowsky
      Ending racism is a journey taken together; the starting point must be now
      Laura Lee Hall and Gary Puckrein
      Increased flu vaccination has never been more important for communities of color
    • It's time we fulfill the ACA's promise to broaden access to lower-cost drugs
      Five lessons for securing our children's future
      We're losing engaged providers, and healthcare will pay the price
      Dr. Chris DeRienzo
      How COVID-19 broke health systems and made them stronger
    • Letters: Eliminating bias in healthcare needs to be ‘deliberate and organic’
      Letters: Maybe dropping out of ACOs is a good thing for patients
      Letters: White House and Congress share blame for lack of national COVID strategy
      Letters: VA making strides to improve state veterans home inspections
    • Sponsored Content Provided By Optum
      How blockchain could ease frustration with the payment process
      Sponsored Content Provided By Optum
      Three steps to better data-sharing for payer and provider CIOs
      Sponsored Content Provided By Optum
      Reduce total cost of care: 6 reasons why providers and payers should tackle the challenge together
      Sponsored Content Provided By Optum
      Why CIOs went from back-office operators to mission-critical innovators
  • Awards
    • Award Programs
    • Nominate
    • Previous Award Programs
    • Other Award Programs
    • Nominations Open - Top 25 Innovators
      Nominations Open May 10 - Top 25 Minority Leaders
      Nominations Open May 24 - Top 25 Emerging Leaders
    • 100 Most Influential People
    • 50 Most Influential Clinical Executives
    • Best Places to Work in Healthcare
    • Health Care Hall of Fame
    • Healthcare Marketing Impact Awards
    • Top 25 Emerging Leaders
    • Top 25 Innovators
    • Minorities in Healthcare
      • - Luminaries
      • - Top 25 Minority Leaders
      • - Minorities to Watch
    • Women in Healthcare
      • - Luminaries
      • - Top 25 Women Leaders
      • - Women to Watch
    • Excellence in Nursing Awards
    • Design Awards
    • Top 25 COOs in Healthcare
    • 100 Top Hospitals
    • ACHE Awards
  • Events
    • Conferences
    • Galas
    • Webinars
    • COVID-19 Event Tracker
    • emburse certify modern healthcare custom media webinar logo lockup
      Sponsored Content Provided By Emburse
      Webinar: Making it easy to manage costs
      virtualmed staff modern healthcare custom media logo lockup
      Sponsored Content Provided By VirtualMed Staff
      Webinar: Best practices for creating a successful telepsychiatry program
      telehealth visit man touching neck while speaking to doctor on computer
      Sponsored Content Provided By Accumen
      Webinar: How telehealth has evolved into a standard of care
      Webinar: Avoid interoperability penalties. Modern Healthcare. Sponsored by Hall Render
      Webinar: Avoiding interoperability penalties
    • Women Leaders in Healthcare Conference
    • Social Determinants of Health Symposium
    • Healthcare Transformation Summit
    • Leadership Symposium
    • Virtual Briefings
      • - Hospital of the Future
      • - Mental Health
      • - Patient Safety & Quality
      • - Strategic Marketing
      • - Virtual Health
      • - Workplace of the Future
    • Best Places to Work Awards Gala
    • Health Care Hall of Fame Gala
    • Top 25 Minority Leaders Gala
    • Top 25 Women Leaders Gala
  • Listen
    • Podcast - Next Up
    • Podcast - Beyond the Byline
    • Sponsored Podcast - Healthcare Insider
    • Video Series - The Check Up
    • Sponsored Video Series - One on One
    • Next Up Podcast: Managing the COVID-19 vaccination rollout with Dr. Gary Little
      Next Up Podcast: Modern Healthcare's editor Aurora Aguilar talks new content direction
      Dr. Chris DeRienzo
      Next Up Podcast: Building team spirit in the wake of COVID-19
      Mikelle Moore
      Next Up Podcast: Mikelle Moore on recognizing all hospital workers during the pandemic
    • Beyond the Byline: Kids' unchecked mental health needs pose long-term consequences
      Beyond the Byline: How COVID-19 has impacted hospital finances
      An older man sitting on a hospital bed with his back toward the camera.
      Beyond the Byline: Upcoding could explain why hospitals are increasingly billing for the most complex treatment
      Beyond the Byline: Insurers are betting on virtual-first plans as COVID-19 shifts care pathways
    • James garvert neustar healthcare insider podcast image
      Building on basics
      Healthcare Insider Podcast Episode Art - Premier
      Why Roger Weems and other consultants are leaving the big firms to join Premier
      James garvert neustar healthcare insider podcast image
      Outreach during COVID-19
      ann barnes healthcare insider podcast image
      Leading with intention to promote diversity and inclusion
    • The Check Up: Kevin Shimamoto
      The Check Up: Kevin Shimamoto of Valley Children's Hospital
      The Check Up: Dr. James E.K. Hildreth
      The Check Up: Dr. James E.K. Hildreth of Meharry Medical College
      The Check Up: Matt Eyles
      The Check Up: Matt Eyles of AHIP
      The Check Up: Dr. Tom Shanley
      The Check Up: Dr. Tom Shanley of Lurie Children’s Hospital of Chicago
    • ivana naeymi-rad one on one intelligent medical objects
      Video: Ivana Naeymi Rad of Intelligent Medical Objects
  • MORE +
    • Advertise
    • Media Kit
    • Newsletters
    • Jobs
    • People on the Move
    • Reprints & Licensing
MENU
Breadcrumb
  1. Home
  2. Government
May 19, 2017 01:00 AM

DOJ's Medicare Advantage lawsuits, investigations likely to change insurance culture

Mara Lee
  • Tweet
  • Share
  • Share
  • Email
  • More
    Print

    The Department of Justice's increased focus on investigating alleged fraud in the Medicare Advantage program is likely to change the way insurers do business, according to lawyers who specialize in False Claims Act suits.

    The Justice Department in recent weeks has filed complaints in two Medicare Advantage fraud suits against UnitedHealth Group. The federal government and whistle-blowers allege the insurer presented false claims to the Medicare program and received at least $1 billion in unjustified payments stemming from inflated patient risk scores.

    The agency is also investigating Aetna, Health Net, Humana and Cigna's Bravo Health to determine if they have been engaging in medical upcoding.

    Risk scores stem from records submitted by providers that contain diagnosis codes, indicating a patient has metastatic cancer, angina, cystic fibrosis, stroke, COPD or other conditions. The more serious the disease, the more Medicare pays the company for each patient.

    Under the fee-for-service model, some doctors weren't dedicated to documenting every condition because that didn't affect how they were paid, especially in outpatient settings.

    "In the traditional fee-for-service world, doctors were getting paid on what procedures they did," said Michael Kolber, a partner at Manatt Phelps & Phillips who specializes in False Claims Act cases. "The plans had an incentive to be vigilant on upcoding and fraud and abuse from providers."

    But under a capitated managed care approach, both insurers and providers get more money if the patients are sicker.

    "In that way, the interest of the provider and the plan is aligned," Kolber said.

    With the insurers no longer a check on providers in this way, it's more difficult for CMS to keep an eye on payments, according to Amy Garrigues, managing partner at the Raleigh office of Hall Render Killian Heath & Lyman.

    "I think it's hard, because of the capitated payment model, it's hard —without restructuring the whole system — it's hard to come up with a way to monitor that," she said.

    It's unlikely the UnitedHealth lawsuits will go to trial, but any settlement could have an impact on the overall Medicare Advantage culture, and it's unclear where the lines will be drawn.

    "You can't verify every claim before you submit it," Kolber said. "How much short of that can you do?"

    UnitedHealth spokesman Matt Burns said the company is confident it complied with Medicare Advantage rules. The DOJ argument ignores that the CMS adjusts Medicare Advantage claims during audits to correct for expected overpayments, he said.

    Garrigues, who usually represents providers, said that sector is already used to auditing of codes, partly because the inpatient payments are based on diagnoses-related groups.

    "But it is something new for the Medicare Advantage insurer," she said.

    According to the complaint filed in federal court in California on Tuesday, some of the physician groups checked by UnitedHealth lacked documentation supporting particular diagnosis codes anywhere from a third to more than half of the time.

    Garrigues said that error rates are a fact of life, but error rates north of 40% are not common. She said for providers, an error rate of under 20% is what they expect to see.

    The complaint alleged that UnitedHealth made sure to add missing codes, but did not delete codes from cases that it couldn't verify.

    Kolber said an associated whistle-blower case against UnitedHealth has set the precedent that if a plan does a retrospective chart review "they have an obligation to look both ways."

    Although some of the details in the UnitedHealth complaints sound egregious, Kolber and Garrigues both said there could be reasonable explanations.

    "I don't think there's a concerted effort by providers to inflate codes for Medicare Advantage patients," Garrigues said.

    Kolber said that UnitedHealth's efforts to verify diagnoses that had been added without enough documentation was portrayed "in the worst possible light." If patient charts don't adequately document real ailments, UnitedHealth's attempts to verify the code "seems like kind of a useful behavior."

    The UnitedHealth cases have garnered attention from lawmakers.

    "If these allegations are true this would represent one of the most egregious defraudings of the government in a long time," Rep. Brian Higgins (D-N.Y.) said in a House Ways and Means Committee hearing on Thursday.

    Medicare Payment Advisory Commission Executive Director Mark Miller said that some of the internal emails quoted in the complaint did seem egregious, and said that generally, "we think there is excess coding occurring," but said that not all coding problems are fraudulent.

    Letter
    to the
    Editor

    Send us a letter

    Have an opinion about this story? Click here to submit a Letter to the Editor, and we may publish it in print.

    Recommended for You
    More than a dozen states to open vaccines to all adults
    More than a dozen states to open vaccines to all adults
    Becerra visits Nevada, stumps for pandemic aid and Obamacare
    Becerra visits Nevada, stumps for pandemic aid and Obamacare
    Sponsored Content
    Get Newsletters

    Sign up for enewsletters and alerts to receive breaking news and in-depth coverage of healthcare events and trends, as they happen, right to your inbox.

    Subscribe Today
    MH Magazine Cover

    MH magazine offers content that sheds light on healthcare leaders’ complex choices and touch points—from strategy, governance, leadership development and finance to operations, clinical care, and marketing.

    Subscribe
    Connect with Us
    • LinkedIn
    • Twitter
    • Facebook
    • RSS
    • Instagram

    Our Mission

    Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data.

    MDHC_Logotype_white
    Contact Us

    (877) 812-1581

    Email us

     

    Resources
    • Contact Us
    • Advertise with Us
    • Ad Choices Ad Choices
    • Sitemap
    Editorial Dept
    • Submission Guidelines
    • Code of Ethics
    • Awards
    • About Us
    Legal
    • Terms and Conditions
    • Privacy Policy
    • Privacy Request
    Modern Healthcare
    Copyright © 1996-2021. Crain Communications, Inc. All Rights Reserved.
    • News
      • This Week's News
      • COVID-19
      • Providers
      • Insurance
      • Government
      • Finance
      • Technology
      • Safety & Quality
      • People
      • Regional News
        • Midwest
        • Northeast
        • South
        • West
      • Digital Edition
    • Insights
      • ACA 10 Years After
      • Best Practices
      • Special Reports
      • Innovations
    • Transformation
      • Patients
      • Operations
      • Care Delivery
      • Payment
    • Data/Lists
      • Rankings/Lists
      • Interactive Databases
      • Data Points
    • Op-Ed
      • Bold Moves
      • Breaking Bias
      • Commentaries
      • Letters
      • Vital Signs Blog
      • From the Editor
    • Awards
      • Award Programs
        • 100 Most Influential People
        • 50 Most Influential Clinical Executives
        • Best Places to Work in Healthcare
        • Health Care Hall of Fame
        • Healthcare Marketing Impact Awards
        • Top 25 Emerging Leaders
        • Top 25 Innovators
        • Minorities in Healthcare
          • - Luminaries
          • - Top 25 Minority Leaders
          • - Minorities to Watch
        • Women in Healthcare
          • - Luminaries
          • - Top 25 Women Leaders
          • - Women to Watch
      • Nominate
      • Previous Award Programs
        • Excellence in Nursing Awards
        • Design Awards
        • Top 25 COOs in Healthcare
      • Other Award Programs
        • 100 Top Hospitals
        • ACHE Awards
    • Events
      • Conferences
        • Women Leaders in Healthcare Conference
        • Social Determinants of Health Symposium
        • Healthcare Transformation Summit
        • Leadership Symposium
        • Virtual Briefings
          • - Hospital of the Future
          • - Mental Health
          • - Patient Safety & Quality
          • - Strategic Marketing
          • - Virtual Health
          • - Workplace of the Future
      • Galas
        • Best Places to Work Awards Gala
        • Health Care Hall of Fame Gala
        • Top 25 Minority Leaders Gala
        • Top 25 Women Leaders Gala
      • Webinars
      • COVID-19 Event Tracker
    • Listen
      • Podcast - Next Up
      • Podcast - Beyond the Byline
      • Sponsored Podcast - Healthcare Insider
      • Video Series - The Check Up
      • Sponsored Video Series - One on One
    • MORE +
      • Advertise
      • Media Kit
      • Newsletters
      • Jobs
      • People on the Move
      • Reprints & Licensing