![]() The plans have been growing rapidly and now serve about 1 in 3 people on Medicare, or about 20 million people. Medicare Advantage plans are privately run alternatives to standard Medicare. Shots - Health News GAO Audit: Feds Failed To Rein In Medicare Advantage Overbilling "Although Medicare managed care is a complex and constantly changing industry in which it is common to have differing interpretations of regulations, with this settlement, we have agreed to resolve disputed claims without any admission of liability in order to avoid delay and the expense of litigation, so that we can focus on providing quality care, member service and maintaining the highest Medicare Star Ratings," Patel said. In a statement, Freedom and Optimum corporate counsel Bijal Patel denied any wrongdoing. She said the settlement "sends an important signal to health insurers that the government is serious about risk adjustment fraud." "This is the largest whistleblower settlement involving health insurers' manipulation of their members' risk scores," said Mary Inman, a San Francisco attorney who represented Sewell. The Sewell case is among the first to settle. ![]() At least a half-dozen whistleblowers have sued health plans alleging they tampered with the billing formula to improperly boost profits. Overspending tied to inflated risk scores has repeatedly been cited by government auditors, including the Government Accountability Office. "This settlement underscores our Office's commitment to civil health care fraud enforcement." Attorney Stephen Muldrow said in a statement. "Medicare Advantage plans play an increasingly important role in our nation's health care market," acting U.S. The payment formula, known as a risk score, has been in use since 2004. The Florida settlement comes amid growing government scrutiny of Medicare Advantage plans, which receive higher payments for sicker patients than for those in good health. Sewell alleged that Medicare overpaid the health plans after the companies made patients appear sicker than they were or claimed patients had been treated for medical conditions they either did not have or for which they had not been treated. He died in 2014, but his family took over the case. Darren Sewell, a physician and former medical director of both plans, who worked for them from 2007 to 2012. The two plans are Freedom Health and Optimum HealthCare, both based in Tampa. The suit, settled on Tuesday, alleged that two of the company's insurance plans exaggerated how sick patients were and took other steps to overbill the government health program for the elderly. A whistleblower lawsuit alleged that two Florida insurance plans inflated fees by making patients appear sicker than they were.įreedom Health Inc., a Florida Medicare Advantage insurer, has agreed to pay nearly $32 million to settle a whistleblower lawsuit.
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