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Medicare Advantage Downstream Provider Settles Risk Adjustment False Claims Allegations

The Department of Justice (DOJ) announced this week that it has entered into a settlement agreement with Davita Medical Holdings (Davita) for $270 million dollars to resolve certain False Claims Act liability related to Medicare Advantage risk adjustment payments.

As the settlement agreement describes, Davita acquired HealthCare Partners (HCP), a large California based independent physician association in 2012. HCP, subsequently Davita Medical Group (or Davita), operated as a medical service organization (MSO) who contracted with Medicare Advantage Organizations (MAOs) to provide services and manage the care of its beneficiaries. Davita would provide beneficiary diagnostic information to its MAOs which would be used by the Centers for Medicare and Medicaid (CMS) to calculate the MAO’s risk adjusted capitated payments under the program’s risk adjustment payment methodology. Payments would then be made by MAOs to DaVita under the terms of its risk sharing arrangements.

The settlement resolved allegations raised in the qui tam action filed in District Court for the Central District of California, United States ex rel. Swoben v. Secure Horizons, et al., by James Swoben, a former employee of a MAO that contracted with HCP. Swoben alleged that HCP hired coding companies to perform “one-way” retrospective reviews of member records, whereby the MAO would submit additional diagnosis codes to CMS but not validate previously submitted codes.

The settlement further resolves allegations related to incorrect coding guidance, unsupported but un-retraced codes identified during audits, in-home assessments, incorrect diagnosis mapping to appropriate ICD-9 codes in its electronic medical record, and acute condition codes in the primary care setting.  In its press release, the DOJ emphasized that the failure by Davita to delete unsupported or undocumented diagnosis codes caused the MAOs to retain payments from CMS that they were otherwise not entitled.

Importantly, Davita as downstream provider to MAOs, did not directly submit claims to the Centers for Medicare and Medicaid. Accordingly, this settlement is extremely significant to downstream entities such as MSOs, IPAs, physician practices and risk adjustment vendors who can themselves potentially be subject to “causes to be submitted” and other theories under the FCA.

©2019 Epstein Becker & Green, P.C. All rights reserved.

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About this Author

Jason Christ, Epstein Becker Law Firm, Washington DC, Healthcare Law Attorney
Member

JASON E. CHRIST is a Member of the Firm in the Health Care and Life Sciences practice, in the Washington, DC, office of Epstein Becker Green. He concentrates in health care fraud and abuse, risk adjustment payment, government investigations, voluntary disclosures, and health regulatory counseling. In 2016 and 2018, he was recommended by The Legal 500 United States in the Healthcare: Service Providers category, and he was cited in 2018 among the "Next Generation Lawyers."

Mr. Christ:

  • ...

202-861-1828
Teresa Mason, Epstein Becker Law Firm, Washington DC, Healthcare Law Attorney
Associate

TERESA A. MASON is an Associate in the Health Care and Life Sciences practice, in the Washington, DC, office of Epstein Becker Green. She concentrates in health care fraud and abuse, risk adjustment coding and payment, government investigations, and health regulatory counseling.

Ms. Mason:

  • Defends a variety of health care entities against federal and state government investigations related to health care fraud and abuse arising under the anti-kickback laws, physician self-referral laws, false claims, and other state and federal fraud statutes

  • Conducts internal investigations related to health care fraud and counsels clients on self-disclosures

  • Counsels clients—including plans, vendors, and providers—regarding Medicare Part C risk adjustment coding and payment including false claims defense, self-disclosures related to overpayment, enforcement counseling, risk adjustment program review, and compliance with Medicare regulations

  • Assists plans with response to CMS sanctions and implementation of program changes

  • Assists Medicare Advantage Organizations with program audits, responses to imposition of civil monetary penalties and/or sanctions, and implementation of program changes

  • Negotiates settlement agreement and corporate integrity agreements in connection with state and federal investigations

  • Designs policies, procedures, and compliance documents

  • Advises clients on legal and regulatory compliance matters arising under Medicare, Medicaid, and other third-party reimbursement programs.

Prior to joining Epstein Becker Green, Ms. Mason worked as a registered nurse in pediatric oncology, bone marrow transplantation, and emergency medicine. She also served as a medical analyst at a boutique litigation firm in the District of Columbia, where she was responsible for researching and analyzing medical information for attorneys who were defending major pharmaceutical companies in class action litigation.

202-861-1838
Thomas E. Hutchinson, Strategic Advisors, EBG Advisors
Strategic Advisor

THOMAS E. HUTCHINSON is a Strategic Advisor for EBG Advisors, Inc. He has more than 25 years of experience in both the private sector and in federal service implementing programs and policies directly affecting Medicare and Medicaid beneficiaries. Mr. Hutchinson advises clients on a wide range of payment policy and operations issues relating to the Centers for Medicare and Medicaid Services (CMS).

Prior to his joining EBG Advisors in this business advisory role, Mr. Hutchinson served as the director of the Medicare Plan Payment...

443-663-1351