On August 10, a federal appeals court resurrected a
whistleblower case against several healthcare companies for
allegedly submitting false risk adjustment data for Medicare
Advantage payments. [U.S. ex rel. Swoben v. United Healthcare
Insurance Co. et al., case number 13-56746, in the U.S.
Court of Appeals for the Ninth Circuit]
The whistleblower alleges that companies conducted biased
retrospective medical record reviews to certify their risk
adjustment data for Medicare Advantage submissions because they
allowed the addition of diagnoses in the audit but did not remove
inappropriate diagnoses. The appeals court held that the
whistleblower could amend his complaint to allege a general
fraudulent pattern and did not need to identify specific fraudulent
claims.
The case is instructive to both Medicare Advantage contractors and
healthcare providers about the importance of accurate coding in
regard to risk adjustment.
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