Report: Medicare Advantage likely to be a fraud enforcement priority in 2019

Federal fraud watchdog agencies may be taking a closer look at Medicare Advantage in 2019, according to a recent report released by Bass, Barry & Sims, a Washington, D.C.-based law firm.

The Healthcare Fraud & Abuse Review 2018 review analyzes major enforcement actions and settlements in 2018 and takes a look ahead at the rest of 2019. The number of recent enforcement actions, settlements, and lawsuits regarding alleged Medicare Advantage fraud, combined with the growing population of Medicare Advantage beneficiaries, makes this a key area to monitor in 2019.

In October 2018, the Department of Justice (DOJ) announced a $270 million False Claims Act settlement with HealthCare Partners Holdings LLC, doing business as DaVita Medical Holdings LLC (DaVita), a Medicare Advantage Organization (MAO). DaVita was alleged to have provided inaccurate information that caused Medicare Advantage plans to receive inflated Medicare payments, according to the DOJ.

The report noted several 2018 district court decisions in False Claims Act cases that saw the odds turn in favor of MAOs. In one case, U.S. ex rel. Poehling v. UnitedHealth Group Inc., the district court dismissed the government’s claims based on the theory that the defendants’ attestations as to the truth and accuracy of the risk adjustment data submitted was false. In the district court’s opinion, the government had not adequately proved that the defendants’ attestations were material to the payment decision. However, the case is proceeding on the government’s claims that DaVita submitted invalid diagnostic data.

Organizations should monitor Medicare Advantage claims and reimbursement and be alert for increased audit and enforcement action targeting MAOs and provider organizations.