(WHTM) -- The U.S. Department of Justice announced Wednesday that Independence Blue Cross has agreed to pay $22.5 million to resolve "allegations that it violated the False Claims Act by failing to withdraw inaccurate and untruthful diagnosis codes for its Medicare Advantage Plan enrollees in order to improperly retain overpayments from Medicare."
IBX, which is incorporated under Pennsylvania laws, allegedly submitted inaccurate and untruthful patient diagnosis data to the Centers for Medicare & Medicaid Services (CMS), per the DoJ, inflating the risk adjustment payments received from CMS, knowingly failing to withdraw the data to repay CMS and falsely certifying that the data was accurate and truthful in writing to CMS.
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Medicare beneficiaries may opt out of traditional Medicare under the Medicare Advantage (MA) Program, also known as Medicare Part C. They can then enroll in private health plans offered by insurance companies known as Medicare Advantage Organizations (MAOs). CMS pays MAOs a fixed monthly rate, which is adjusted for various risk factors that affect expected health expenditures for the beneficiary.
The DoJ stated that, in general, "CMS pays MAs more for sicker beneficiaries expected to incur higher healthcare costs," and in order to make risk adjustments, CMS "collects medical diagnosis codes from the MAOs."
Between 2017 and 2021, IBX's chart...
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