Capitated Doc Is Indicted in First MA Upcoding Criminal Case in S. Fla.

If you have been sleeping under a rock, you may not be aware of this risk adjustment legal case in Florida.  Otherwise, you are wondering how it will turn out and what it will reveal about what really went on in Del Rey, Florida. The question is really about what was done by whom, where were legal lines crossed and who all is going to end up paying the piper.  

The indictment states that this is an alleged case of fraud at the level of a particular provider's two offices.  The provider had been operating under a capitated risk arrangement through one of the largest MA plans in the country.  My understanding is that the contention is that there was intentional upcoding of ICD-9 codes to inflate the upstream CMS premiums paid to the MAO which then filtered down to the provider on a member-specific basis, generating inappropriately high payments in the revenue stream.  The actual health care conditions were deliberately exaggerated, according to the U.S. Attorney's Office, and the excess funds were not dedicated to payment for health care for the members but rather were diverted to personal use by the provider. 

According to the brief article from Medicare Advantage News, the DOJ is silent about their opinions regarding the liabilities of the upstream MA Organization.  Hence, the watchful waiting.  

As the RISE Association, we are interested in collaborating with our members on putting together a set of standards and best practices for MA healthplans to follow in order to have a practical and robust risk mitigation program for their risk adjustment efforts.  There is no place for the "head-in-the-sand" strategy.  Nor is there a practical option of "doing everything everywhere that might conceivably avoid exposure to risks".  But there is such a thing as creating a program that is keyed off the existing guidance, and continuously improved as more information becomes available.  Stay tuned for more in this theme.  Please contact Kevin Mowll, Executive Director of RISE, if you have any suggestions or comments:


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