Recently, Martin’s Point Health Care Inc. reached a $22.485 million settlement over allegations that it violated the False Claims Act by submitting inaccurate diagnosis codes for its Medicare Advantage Plan enrollees, to increase reimbursements from Medicare.
Martin’s Point operates Medicare Advantage plans for MA beneficiaries in Maine and New Hampshire under Medicare Parts C and D. According to the United States, from 2016 to 2019, Martin’s Point engaged in chart reviews of their MA beneficiaries to identify additional diagnosis codes that were not submitted to Medicare. The government further alleged that Martin’s Point went on to submit those diagnosis codes, despite lack of support in the medical records for the diagnosis codes, which resulted in higher payments from the Centers for Medicare and Medicaid Services (CMS).
The settlement notes that since 2019, Martin’s Point has made leadership and personnel changes, as well as changes to its Board of Directors. It also requires that Martin’s Point review for any unallowable costs included in payments previously sought from the United States or any state Medicaid program. The United States is also allowed to recoup any overpayment (plus applicable interest and penalties) as a result of the unallowable costs.
The settlement resolves claims brought under the qui tam provisions of the False Claims Act by a former manager in the Risk Adjustment Operations group at Martin’s Point. The whistleblower will receive roughly $3.8 million for their involvement. Of the $22,485,000 settlement, $12,491,883.22 is restitution.
A spokesperson for Martin’s Point said, “This settlement is not an admission of liability, it instead allows us to avoid the disruption, expense, and uncertainty of litigation. It is important to note that this investigation is unrelated to member care or payment of member claims. This resolution allows us to put the past behind us, and we remain committed to our patients and members across our service regions and to the regulatory agencies that oversee our work.”
“It is a privilege for health plans to provide services to Medicare beneficiaries, not a right. Medicare Advantage Plan sponsors that submit inaccurate claim information in order to justify inflated payments undermine the financial integrity of the program,” said Deputy Inspector General for Investigations Christian J. Schrank at the Department of Health and Human Services, Office of Inspector (HHS-OIG). “HHS-OIG remains committed to protecting taxpayer-funded health care programs, including Medicare Advantage.”