Diagnosis coding practices in the Medicare Advantage (“MA”) risk adjustment space continue to be a top enforcement priority for the Department of Justice (“DOJ”). Last month, DOJ announced the latest such resolution: a $14.1 million settlement with Complete Health Partners Holdings, LLC (“Complete Health”) to resolve allegations that it caused the submission of false diagnosis codes in violation of the False Claims Act (“FCA”). This settlement follows a series of recent MA risk-adjustment enforcement actions across the industry, from health plans to management services organizations to in-home assessment vendors, and offers a useful window into DOJ’s current thinking on programs designed to generate diagnosis coding suggestions, particularly those programs that enter suggestions directly into the electronic medical record (“EMR”) or focus on a particular set of billing codes.
The Settlement. The underlying case, United States ex rel. Bowers v. Complete Health Partners, Inc., et al., No. 3:22-cv-463 (M.D. Fla.), was brought under the qui tam provisions of the FCA by a former employee of the two Medicare Advantage Organization (“MAO”) co-defendants. The United States intervened in the case only to settle certain claims against Complete Health. The claims against the two MAO co-defendants and Complete Health’s private equity owner and operator Pharos Capital Group, LLC will be dismissed without prejudice as to the United States.
The Government contends in the settlement...
Return to all news DES MOINES, IA – Yesterday, Zach Lahn released a new ad that follows the same pattern of nearly all of his ads so far – it’s filled with lies. Lahn’s latest ad includes several ...