Former Medicare Advantage Executive charged in multi-million fraud scheme

[pnwmom]

https://www.justice.gov/opa/pr/former-executive-medicare-advantage-organization-charged-multimillion-dollar-medicare-fraud

The Justice Department today announced charges against a former executive at HealthSun Health Plans Inc. (HealthSun), a Medicare Advantage organization that operates Medicare Advantage plans in South Florida, for her role in a multimillion-dollar Medicare fraud scheme.

In addition, the Justice Department announced that it has declined prosecution of HealthSun after considering the factors set forth in the department’s Principles of Federal Prosecution of Business Organizations and the Criminal Division’s Corporate Enforcement and Voluntary Self-Disclosure Policy, including HealthSun’s prompt voluntary self-disclosure, cooperation, and remediation, as well as HealthSun’s agreement to repay the Department of Health and Human Services’ Centers for Medicare & Medicaid Services (CMS) approximately $53 million in overpayments.

According to court documents, Kenia Valle Boza, 39, of Miami, formerly the Director of Medicare Risk Adjustment Analytics at HealthSun, allegedly orchestrated a scheme to submit false and fraudulent information to CMS to increase the amount that HealthSun received for certain Medicare Advantage enrollees. CMS pays Medicare Advantage plans like those HealthSun operates based, in part, on the health condition of their enrollees. To increase the company’s profits and their own compensation, Valle and her co-conspirators are alleged to have knowingly submitted and caused the submission to CMS 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, such as coders, added to patient health records.

For example, Valle 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 those conditions. In addition, Valle and her co-conspirators allegedly obtained the login credentials assigned to certain physicians to wrongfully access electronic medical records (EMR) as the physicians, and falsely and fraudulently entered chronic conditions directly into the medical records of beneficiaries. These diagnoses appeared to have been made and documented by the physicians when, in truth and fact, coders entered the conditions into beneficiaries’ medical records, often days or weeks after the physician saw the beneficiary. As a result of the scheme, Valle and her co-conspirators allegedly caused HealthSun to submit to CMS tens of thousands of false and fraudulent diagnosis codes, which resulted in CMS overpaying HealthSun millions of dollars.

[dalton99a]

1. Tip of an iceberg

[XanaDUer2]

2. Exactly eom

[leftstreet]

3. Who would of thought privatizing healthcare leads to fraud

Shoveling millions of dollars to private contractors with no oversight until AFTER pockets are lined

[Silent Type]

7. While I agree with your post, there is also fraud in traditional Medicare. In fact, it's substantially more than in MA.

For 2019 and 2020 traditional Medicare "improper payments were roughly $26 B vs. $17 B under MA. The worst fraud is under Medicaid.

https://www.cms.gov/newsroom/fact-sheets/2020-estimated-improper-payment-rates-centers-medicare-medicaid-services-cms-programs

[pnwmom]

8. There are substantially more people on MA now than in 2019-20. So the numbers would be higher now. nt

[Silent Type]

9. Maybe. But CMS has cracked down on the primary source of MA fraud, diagnoses upcoding.

That's not where the source of traditional Medicare fraud comes from, it's mostly providers.

[malaise]

4. Get thee to the greatest page to expose

this criminal and her cronies

[MiniMe]

5. They have to make their money from somewhere to pay for all the advantage commercials

I am so sick of them. I thought they were going to stop sometime over the summer, but they never stopped. Augh

[underpants]

6. Florida huh?

[TheRealNorth]

10. That was my thought as well

A lot of insurance-related healthcare fraud down there it seems. Probably d/t competition of who has the biggest boat.