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Anthem must face Medicare Advantage fraud lawsuit, judge rules

October 4, 2022
Modern Healthcare
By Nona Tepper

Anthem must face a Justice Department lawsuit alleging the Medicare Advantage insurer intentionally submitted inaccurate patient information to the federal government that allowed it to fraudulently collect more than $100 million in overpayments.

Judge Andrew Carter handed down the ruling in the U.S. District Court for the Southern District of New York on Friday, denying Anthem’s bids to dismiss the case or move the venue to a federal court in Ohio. The Justice Department sued Anthem in March 2020, alleging the insurer violated the False Claims Act by submitting inaccurate patient data as a way to capture additional payments through the Medicare Advantage program.

Neither Anthem nor the Justice Department immediately responded to interview requests.

Health insurance companies are paid a flat fee to manage care for patients enrolled in Medicare Advantage. The Centers for Medicare and Medicaid Services determines that fee, in part based on the number and severity of medical conditions a patient suffers from. This payment methodology incentivizes Medicare Advantage insurers to capture as many patient conditions as possible through chart reviews, home health assessments, primary care visits and more.

From 2014 to 2018, Anthem combed its Medicare Advantage members’ medical charts to find as many diagnosis codes as possible to submit to CMS, the lawsuit alleges. In the process, the insurer chose not to delete thousands of inaccurate diagnosis codes listed because that would have reduced its revenue through the program, the complaint alleges.

“The financial costs to the government here are substantial and not merely administrative costs,” Carter wrote in the opinion, which was released Monday. He denied Anthem’s bid to dismiss the case over a lack of materiality.

The insurer also argued that the case should be heard at a federal court in Ohio because employees at its office in Columbus, Ohio, were charged with submitting diagnosis codes to CMS. Carter ruled the case should be heard where Anthem leaders were located.

“The locus of operative facts for the purposes of this motion should be determined by the location of the decisionmakers. The facts point to a fraud scheme in which key decision makers, namely Anthem executives, pushed for a policy of revenue maximization in lieu of legal compliance,” Carter wrote.

The Justice Department has sued other Medicare Advantage plans for allegedly overbilling the federal government for their services. But the primary way health plans are held accountable through the program is via federal audits of their risk adjustment practices, known as RADV audits. CMS has said it has plans to release a series of audits dating back to 2011 that will result in more than $600 million in recouped overpayments by the end of the year.

The agency has also proposed changing how these audits are conducted by removing Medicare Advantage insurers’ comparison to traditional Medicare, a technical change that would eliminate the “fee-for-service adjuster.” Health plans are opposed to the rule, which could increase the amount owed in overpayments by $381 million annually. CMS is scheduled to release a long-awaited final rule updating this measure in November.

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