One of the main themes of this year’s RISE National is the need to be flexible and ready to pivot due to the uncertain Medicare Advantage and health care environment. And while the political and regulatory landscape is unclear, the conference spotlighted the work individuals and organizations are doing to improve health care and the member experience, remain compliant, and advocate for the most vulnerable of our populations. Here are three highlights.
Success story: Whistleblower Teresa Ross offers insight into her 12-year risk adjustment fraud lawsuit
Teresa Ross (pictured above, middle) joined her attorneys Mary Inman (pictured left) and Max Voldman(pictured right) of Whistleblower Partners LLP to talk about her 12-year lawsuit against health insurers Group Health Cooperative (GHC), a Seattle area Medicare Advantage organization, and Independent Health (IH), a Western New York Medicare Advantage organization, for alleged risk adjustment fraud.
Ross, former director of risk adjustment at GHC, filed a lawsuit in April 2012 against GHC, IH, DxID, a coding vendor owned by IH, which provided services to both GHC and IH, and two of DxID’s executives, including CEO and founder Betsy Gaffney. She claimed that the coding vendor did not follow CMS rules for coding, which led GHC and IH to knowingly submit improper codes to the Medicare Advantage program.
In December 2024, Ross finally reached a settlement with IH, DxID, and Gaffney of up to $100 million with Ross receiving a share of 22.5 percent of the settlement. GHC agreed to pay $6.375 million in 2020 to resolve the allegations.
According to Ross, the fraud began after GHC had a bad financial year. That’s when the CEOs from GHC and IH met at a conference and the IH CEO said he had a way for GHC to make a lot of money. GHC hired the coding vendor, which was paid based on a percentage of what they were reimbursed.
“That led to an incentive for the vendor to clearly upcode because they got 20 percent of whatever they could recover. The way they went about that was to basically ignore the guidance that CMS put out,” she said. Among the violations: coding from lab tests, coding all patients on oxygen as hypoxic, and coding chronic kidney disease from GFRs. “There was a variety of things going on and every expert in the company, all of the coders, said ‘I don’t think so. This is not how we do things.’ They actually had another vendor come in and say, ‘absolutely, we would not do this.'”
Despite the objections, the upcoding continued. Indeed, Ross fought for a year-and-a-half for the company to stop the upcoding. And yet, the company asked Ross to sign an internal attestation that she agrees that the data submitted is accurate, complete, and correct. She refused to sign it and sought the advice of an employment attorney, who told her the case was more than saving her job. It was fraud.
Ross urged attendees, if they are ever in a similar situation, to go through every internal channel possible before resorting to a lawsuit. She described her journey as isolating and lonely. Before she left the company, GHC brought a counselor into her office to tell her she was wrong for not going along with the company.
“Think about this for a minute,” Inman said, noting that the decision to bring a psychological counselor equated to gaslighting. “The idea would be everyone else seems to be going along. Should we be checking your mental health? It’s shocking.”
Ross found another job and left the company but once the case was unsealed, her new employer let her go. Inman said that Ross not only lost her job but also her coworkers and friends.
“Nobody likes the whistleblower, nobody likes the snitch, is the idea,” Inman said. “Not only are they not disloyal, they’re your most loyal employee.”
Inman said that it doesn’t matter the industry, there is a corporate playbook when it comes to whistleblowers. “It’s somehow in our DNA that wen someone has the temerity to speak up, we get in a defensive posture and it's like a cornered animal.”
Companies need to have a growth mindset and look internally about how they are doing and thank the employees who warn us of bad behavior, Inman said. They should be thanking the employee for alerting them to the problem, instead of pointing the finger at the employee and saying, ‘you’re the problem, you must have a mental health issue.’ “It’s extraordinary and this still goes on every day,” Inman said.
Inspiration from RISE Trailblazer award winner
Shannon Wilson, VP, population health & health equity, Priority Health, winner of this year’s prestigious RISE Trailblazer award, accepted the honor with the following words:
“As a child I was taught that to whom much is given, much is required. Something instilled in me by my parents who are both hard working, who I hope I've made proud today. Over the course of my career, I've tried really hard to honor this commitment, working tirelessly to uplift the quality of care our seniors receive, especially those who have given so much but lack the resources to really age gracefully and on their terms.
We all have our why. And my why is a 95-year-old woman by the name of Louise Salter, who lives in an apartment by herself in Detroit, Mich. I affectionately call her Granny. She has chosen to live at home, and I am determined to create an ecosystem for her and other individuals like her in our society that have earned this right.
So, whether it is food, housing, social isolation, diabetes, cancer care, or any of the work that each of us in this room does today, you are all playing an important role in bringing this dream to reality and ensuring that our oldest adults have access to the best innovations and care possible.
The award bestowed upon me today pays tribute to Dr. Martin L. Block and his efforts to inspire positive change. And in a world of chaos and disruption, I think we are all looking for a little bit of positivity. Malcolm X once said, the future belongs to those who believe in the beauty of their dreams. And today I encourage you to join me as I tend to dream big because we have big challenges ahead of us. However, I know that with each of us in this room, the power that we hold, we can impact change that is going to last for years to come.”
Keynote Justin Wren on finding a purpose, making a meaningful impact
Keynote Justin Wren, elite UFC/MMA fighter turned global humanitarian and founder of Fight for the Forgotten, shared the awe-inspiring story of his life. He recounted the pain of being mercilessly bullied throughout his childhood, his transformation into a champion MMA fighter, and his path into painkiller addiction, depression, and attempted suicide. It wasn’t until a chance collection of circumstances led Wren to live in the rainforest among the Pygmy people that he found his true purpose to help others. Here are a few of his inspriational quotes from the keynote:
“What meaningful impact would you make if you only knew you could in the lives of others in your communities? What meaningful impact would you make if you only knew you could?”
“If you want to go fast, go alone. But if you want to go far, go together…You're at this conference, you are here at RISE because you want some education and inspiration, but also connection with each other. Simply put, we don't have to do life alone. We're better together.”
“If you think you are too small to make a difference, try sleeping in a closed room with mosquito.”
“We vastly underestimate the impact we can have in people's lives. People that are right beside us right now, people that are right in front of us, right behind us, we can all make a difference."
“So, I'm not asking anyone to uproot their lives. And in the rainforest, frankly, they don't want us all there anyways. But what I will remind us of today is that we can all make an impact. We can all make a difference."