What is Medicare Advantage fraud?

Medicare Advantage (also called Medicare Part C) is an alternative to “fee for service” Medicare.  Private Medicare Advantage plans contract with the federal government to cover all of a patient’s healthcare needs, rather than charging the government for each individual service. 

The government pays insurers a fixed monthly amount per patient, which is determined by the patient’s “risk-adjustment factor.”  It pays more for patients with serious health conditions, because those patients require more treatment. 

Medicare Advantage fraud occurs when an insurer knowingly submits (or causes a contractor to submit) inaccurate risk-adjustment data to artificially inflate a patient’s risk-adjustment factor.  Such fraud potentially causes the government to pay the insurer more per patient, even when the Medicare Advantage plan is not providing greater services to that patient.  This violates the False Claims Act (FCA).

The government has focused closely on allegations of Medicare Advantage fraud.  In one FCA case, it alleged that a major insurer sent nurse practitioners to patients’ homes to make improper diagnoses.  It claimed the nurses lacked the necessary equipment to make diagnoses and should not have made such diagnoses in the patient’s home.  The government has also pursued similar suits alleging insurers inflated patients’ risk adjustment factors.

Proving Medicare Advantage fraud often requires expert analysis of whether risk adjustments were medically appropriate and permitted by applicable statutes, regulations, and agency guidance.

To learn more about the False Claims Act and other whistleblower programs, go to www.mololamken.com and follow us on LinkedIn.  “Brilliant lawyers with courtroom savvy” — Benchmark Litigation.  Copyright MoloLamken LLP 2023.