Health care company agrees to pay $22.5 million to settle claims of over billing

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A health care company agreed to pay nearly $22.5 million to resolve claims that it violated U.S. laws by over billing government health plans.

Portland, Maine-based Martin’s Point Health Care Inc. agreed to pay $22,485,000 to resolve allegations that it violated the False Claims Act by submitting inaccurate diagnosis codes for its Medicare Advantage Plan enrollees in order to boost reimbursements from Medicare, according to the U.S. Department of Justice.

“The government expects those who participate in Medicare Advantage to provide accurate information to ensure that proper payments are made for the care received by enrolled beneficiaries,” said Deputy Assistant Attorney General Michael Granston of the Justice Department’s Civil Division. “Today’s result sends a clear message to the Medicare Advantage community that the United States will take appropriate action against those who knowingly submit inflated claims for reimbursement.”

Under Medicare Advantage, known as the Medicare Part C program, beneficiaries have the option of enrolling in managed care insurance plans called Medicare Advantage Plans. Medicare Advantage Plans are paid a per-person amount to provide Medicare-covered benefits to beneficiaries who enroll in one of their plans.

The Centers for Medicare and Medicaid Services, which oversees the Medicare program, adjusts the payments to Medicare Advantage Plans based on demographic information and the diagnoses of each beneficiary. The adjustments are referred to as “risk scores.”

In general, a beneficiary with diagnoses more expensive to treat will have a higher risk score, and the Centers for Medicare and Medicaid Services will make a larger risk-adjusted payment to the plan for that beneficiary.

Martin’s Point operates Medicare Advantage plans for beneficiaries living in Maine and New Hampshire. Federal prosecutors alleged that from 2016 to 2019 the company engaged in chart reviews of their Medicare Advantage beneficiaries to identify additional diagnosis codes that had not been submitted to Medicare.

Many of the additional codes submitted, however, were not properly supported by the patients’ medical records. Prosecutors alleged that Martin’s Point nevertheless submitted those diagnosis codes, which resulted in higher payments from the Centers for Medicare and Medicaid Services.

“It is a privilege for health plans to provide services to Medicare beneficiaries, not a right. Medicare Advantage Plan sponsors that submit inaccurate claim information in order to justify inflated payments undermine the financial integrity of the program,” said Deputy Inspector General for Investigations Christian Schrank at the Department of Health and Human Services. “HHS-OIG remains committed to protecting taxpayer-funded health care programs, including Medicare Advantage.”

Whistleblower Alicia Wilbur, a former manager in Martin’s Point’s Risk Adjustment Operations group, will get about $3.8 million.

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