As the government continues to rely on whistleblowers to combat healthcare fraud, greater focus may turn to Medicare Advantage Plans.
Last year the government recovered over $3 billion with the help of whistleblowers under the False Claims Act (FCA). Fraud recoveries from the healthcare sector alone accounted for $2 billion.
Recently, a group of senators raised concerns that Medicare Advantage plans were overbilling Medicare, citing a government report that found $30 billion of overpayments over three years. Medicare Advantage plans—also known as Medicare Part C—are operated by private organizations. These groups charge the government based on the number of beneficiaries enrolled in their program. Medicare adjusts the specific payment to these plans based on “risk score” that factors in the severity of beneficiaries’ diagnoses.
Private Medicare Advantage plans may attempt to defraud the government by submitting unsubstantiated codes for beneficiary diagnoses to inflate the risk score. In 2019, the Department of Justice (DOJ) announced that one provider had agreed to pay $30 million to settle allegations of just such a plan.