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Medicare Advantage Insurers Reach $32 Million Settlement in Whistleblower Case

A pair of Medicare Advantage insurers based in Florida agreed to pay nearly $32 million to settle a whistleblower claim.

In the claim, a whistleblower alleged the insurance providers routinely exaggerated the severity of patients’ conditions and took various other steps to overbill Medicare. The suit was initially filed in 2009 by Dr. Darren Sewell, a former medical director at Freedom Health and Optimum HealthCare, the two insurers named in the suit. Dr. Sewell passed away in 2014, but his family took over the claim upon his death.

In the lawsuit, Dr. Sewell alleged Medicare overpaid the two health plans after the insurers claimed they had treated patients for conditions they either did not have or for which they had not actually received treatment. By making the patients look sicker than they were, the insurers stood to receive more money from Medicare.

Medicare Advantage plans the subject of scrutiny

This latest settlement comes as federal lawmakers are beginning to pay more attention to Medicare Advantage plans, which use a payment formula known as a “risk score” to determine how much Medicare will pay out based on the condition of the patients. The plans are playing a larger role than ever in the healthcare market across the United States, which means lawmakers and compliance agencies must focus even more on preventing healthcare fraud and enforcing the law.

This recent case was the largest ever whistleblower settlement involving the manipulation of member risk scores by health insurers. It indicates that the government is serious about cracking down on this type of fraud and may richly reward whistleblowers for their assistance.

If you would like to report an instances of healthcare fraud, speak with an experienced Dallas attorney at Whistleblower Law for Managers

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