The Department of Justice (“DOJ”) recently filed a False Claims Act suit alleging that Anthem falsely certified the accuracy of diagnosis data that it submitted to the Centers for Medicare and Medicaid Services (“CMS”) for services provided to Medicare Advantage beneficiaries. As a result of the inaccurate and inflated information, Anthem obtained millions of dollars in Medicare funds to which it was not entitled, according the suit.
The suit was brought by the US Attorney for the Southern District of New York. The suit alleges that Anthem, a Medicare Advantage Organization (“MAO”), submitted inaccurate diagnosis data from beneficiaries’ healthcare providers to CMS. CMS then used that data calculate a “risk score” and, in turn, the amount of capitated payment that Anthem would receive for each beneficiary. Anthem employed the services of MediConnect, a third-party vendor, to complete a “retrospective chart review” in which MediConnect collected medical records from healthcare providers detailing the services they provided to Anthem’s Medicare Advantage beneficiaries. The healthcare providers were told that this was part of routine “oversight activity” to “help ensure that the [diagnosis] codes have been reported accurately.” MediConnect then reviewed the medical records to identify all of the diagnosis codes supported by those records, and then passed those on to Anthem who submitted them to CMS, if they had not already been submitted based on what the healthcare providers had already reported.
However, the suit alleges that when the MediConnect review did not validate diagnosis codes that Anthem had already submitted to CMS, Anthem “did not make any effort to verify or delete those codes.” According to the complaint, removing the invalid codes would have substantially reduced the additional revenue, frequently in excess of $100 million per year, the chart review program generated. The suit also alleges that Anthem repeatedly made false statements to CMS, specifically making annual attestations verifying the accuracy of its risk-adjustment date submissions, and telling CMS that it would research and correct risk adjustment discrepancies.
Commenting on the case, Manhattan US Attorney Geoffrey Berman noted that “[t]he integrity of Medicare’s payment system is critical to our healthcare. This Office is dedicated to vigorously using all of the legal tools available, including the False Claims Act, to ensure the integrity of Medicare payments. The case against Anthem … is an illustration of that commitment.”
The DOJ is asking for treble damages, civil penalties and restitution.