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.