Recently, the United States Department of Justice (DOJ) filed charges against Kenia Valle Boza, a former HealthSun Health Plans executive, for her role in an alleged multimillion-dollar Medicare fraud scheme.
According to the DOJ, Valle Boza allegedly orchestrated a scheme to submit false and fraudulent information to the Department of Health and Human Services’ (HHS) Centers for Medicare and Medicaid Services (CMS) to increase the amount that HealthSun received for certain Medicare Advantage enrollees. Specifically, Valle Boza and her co-conspirators allegedly knowingly submitted and caused the submission of false and fraudulent information about chronic ailments that Medicare beneficiaries in HealthSun’s plans did not actually have, and that non-health care providers (i.e., coders) added to patient health records.
For example, Valle Boza and her co-conspirators allegedly entered– and caused others to enter – diagnoses into the medical records of beneficiaries enrolled in HealthSun’s plans based on diagnostic tests that were not a proper basis for diagnosing the conditions. Valle Boza and her co-conspirators allegedly did this by obtaining the login credentials assigned to certain physicians to wrongfully access the electronic medical records as the physicians and then falsely and fraudulently enter chronic conditions into the medical records of beneficiaries. This made it appear as thought the diagnoses were made and documented by the physician when in reality, coders often entered the conditions into the beneficiaries’ medical records, often days or weeks after the physician saw the beneficiary. This led to tens of thousands of false and fraudulent diagnosis codes being submitted to CMS, which in turn caused CMS to overpay HealthSun by millions of dollars.
Under the indictment, Valle Boza is charged with one count of conspiracy to commit health care fraud and wire fraud, two counts of wire fraud, and three counts of major fraud against the United States. If convicted, a maximum penalty of 20 years in prison is possible on the conspiracy count and each wire fraud count while a maximum penalty of 10 years in prison is possible on each count of major fraud against the United States.
The DOJ also announced that it declined prosecution of HealthSun, after considering the factors set forth in the Principles of Federal Prosecution of Business Organizations and the Criminal Division’s Corporate Enforcement and Voluntary Self-Disclosure Policy. Some of the factors considered included HealthSun’s prompt voluntary self-disclosure, cooperation, and remediation, as well as the agreement by HealthSun to repay CMS roughly $53 million in overpayments.