The Fraud Risk of Diagnosis Upcoding in the Medicare Advantage Risk Adjustment Program

Medicare Advantage Risk Adjustment Fraud

The Office of Inspector General of the Department of Health and Human Services recently released a report that showed that diagnosis upcoding continues to be a problem in the Medicare Advantage risk adjustment program. According to their findings, Essence Healthcare received at least $158,904 of overpayments from the Centers for Medicare & Medicaid Services (CMS) program. Unfortunately, Essence Health is not the only guilty party in healthcare who has received such overpayments. A report published by the New York Times in 2017 showed that UnitedHealth allegedly used diagnosis upcoding to over-bill Medicare by billions of dollars. Understanding Diagnosis Upcoding at a Glance Diagnosis upcoding is a phrase used to describe what happens when a medical provider or insurance company reports or documents that a patient was treated for a disease or condition that the patient either does not have or was not treated for. Because insurers and some providers in the Medicare Managed Care program get paid more from the Government for certain types of conditions, there is a higher risk of diagnosis upcoding to try to get more funding. Unfortunately, the way the system is set up it almost encourages healthcare providers to upcode, which is proving to be problematic in causing a seemingly ongoing issue. Why Whistleblowers Should Help Combat Problems with Diagnosis Upcoding Diagnosis upcoding hurts everyone, right down to the patients who are receiving care. For one, upcoding diagnoses leads to what looks to be an appearance of higher rates of certain illnesses and conditions among the general… Read more »

Defendants Should Welcome Whistleblowers: New Department of Justice Guidelines on Credit for Cooperation in False Claims Act

Whistleblower Hero

For many years, the Department of Justice (DOJ) has worked hard to encourage companies to cooperate during an investigation after a False Claims Act case has been filed. While some companies have taken initiatives to make whistleblowers more comfortable about stepping forward, many still choose the path of obstruction and retaliation instead. The DOJ recently released new guidelines to encourage further cooperation from defendants. Cooperation Defined According to the DOJ DOJ’s policy provides incentives for the following types of cooperation: Voluntary disclosure about a potential False Claims Act violation Sharing information learned during an investigation into the claim on an internal level Implementing new compliance programs within the company to handle reports Offering insight beyond what the DOJ is already investigating Taking remedial measures as soon as the investigation is opened Disclosing misconduct that the DOJ suspects or is outside of what is already suspected Notably, an informed whistleblower can often help a company with each of these steps, by providing a roadmap to aspects of the misconduct that it might otherwise take investigators significant time to discover and understand Rewards for Cooperation In exchange for cooperation, the guidelines provide that the defendant could get credit in the form of reductions in damages multipliers used to determine settlements or reduced civil penalties. If there are administrative overseers involved, the DOJ will work to inform those overseers of the company’s willingness to cooperate so it can be considered if further action has to be taken through those administrations. Companies who get credit… Read more »