Search Site

Whistleblower Accuses Medicare Advantage Organizations of Overbilling

A Texas whistleblower has filed a lawsuit against CenseoHealth LLC and various other Medicare Advantage organizations, claiming they have been regularly overcharging Medicare for the in-home care they provide to patients.

The plaintiff is Becky Ramsey-Ledesma, a former coding manager for Censeo, and she has demanded her claim be presented in a jury trial. The documents for the case were unsealed in June after the U.S. Department of Justice decided it would not intervene in the case.

Claims of inaccurate coding

According to these documents, Ramsey-Ledesma says Censeo knew patient diagnoses were not matching up with the documentation of medical records, but were being “picked up” from predicted diagnoses based on the medications being taken by patients. If the prescribed medication could support a specific diagnosis, care providers were allegedly instructed to code for that diagnosis — even if it was not accurate.

The case pinpoints Mark Dambro, chief medical officer at Censeo, as the individual who developed an in-depth evaluation process specifically geared toward maximizing the capitated payment rates given to Medicare Advantage organizations that were clients of Censeo.

Ramsey-Ledesma alleges that rather than relying on the records provided by doctors treating patients, Censeo instead took self-reported information directly from certain members of Medicare Advantage organizations. This information was allegedly collected via evaluation forms filled out by doctors retained by Censeo to establish ICD-9 codes to submit to the Centers of Medicare and Medicaid Services.

If your business or organization needs to conduct a thorough internal investigation, meet with a skilled Dallas attorney at Whistleblower Law for Managers for further guidance.

Leave a Reply

Your email address will not be published. Required fields are marked *

Awards & Honors
Our Office
  • Dallas Office
    4514 Cole Ave
    Dallas, Texas 75205
    Phone: 214-306-8045
    Fax: 469-729-9926
As Seen In
In his new book, "Standing Up to China: How a Whistleblower Risked Everything for His Country," former client & Author, Ashley Yablon, quotes Attorney Steve Kardell about Whistelblower Law.
  • "Steve Kardell was terrific in representing me in some very adversarial discussions with Citigroup and also later represented me in my testimony before the Financial Crisis Inquiry Commission."  -Richard Bowen, Citigroup Whistleblower

  • "Incredible knowledge of employee related concerns and equally brilliant knowledge of health care regulations, standards of practice. I would recommend this firm to anyone."  -V.B.

  • "Reaching out to Steve Kardell was the best decision I made. His ability to provide immediate insight and direction was very powerful, and a huge relief during a very stressful time period. For anyone struggling with a whistleblower situation, I would highly recommend at least speaking with Steve. After a 10 minute call with him, I had a better understanding of what I was dealing with. Even better, he gave me some immediate hope. In the end Steve did a better job than I thought was possible. Steve was able to get in contact with people in my organization, that I didn’t have access to. Because of his years of experience, he already has contacts in many organizations in Dallas. The entire situation was handled peacefully. I was impressed by his ability to “keep the peace”–rather than creating a battle with the organization. The reason I didn’t reach out to a lawyer initially, was because I thought it would mean an immediate end to any hope of a positive relationship with the company. Steve was able to address my concerns, and in the end I was able to continue to work for them."  -KS

  • "Never thought my career would end like it did after 30 years of service. I was part of the first round of the so called reduction of force. I asked myself how can I be part of this with 30 years of seniority. How did they pick these 90 plus employees? Now, the culture of this organization made you question every decision they made. It wasn’t what you knew it’s was a culture of who you know. Nonetheless, I did not accept their severance package. I immediately starting looking for an attorney who would take on my case. After the initial call to Steve I had hope again. He was open and honest about everything and reassured me he would do his best for me, and he did. I had an awesome outcome. Thanks Steve you’re the best."  -S.S.