Affiliates of Kaiser Permanente have agreed to pay $556 million to resolve allegations that they improperly boosted Medicare Advantage payments over nearly a decade by submitting invalid diagnosis codes, in one of the largest False Claims Act settlements to date involving the fast‑growing program.
The settlement, announced Wednesday by the Justice Department, caps a government investigation into what prosecutors described as a years‑long, highly structured effort by Kaiser to “game the system and pad their profits” by retrospectively inflating risk scores for Medicare Advantage enrollees in California and Colorado.
Kaiser, an integrated healthcare consortium headquartered in Oakland, Calif., owns and operates Medicare Advantage Organizations that offer plans nationwide. The settling affiliates are Kaiser Foundation Health Plan Inc.; Kaiser Foundation Health Plan of Colorado; The Permanente Medical Group Inc.; Southern California Permanente Medical Group; and Colorado Permanente Medical Group P.C.
While the resolution is civil and Kaiser does not admit liability, the case sends an unmistakable signal to health insurers and risk‑bearing medical groups that the federal government is intensifying scrutiny of risk‑adjustment practices in Medicare Advantage – with direct consequences for insurers’ compliance, governance and financial exposure.
At the heart of the government’s complaint is the complex mechanism by which Medicare Advantage...
Whistleblowers could get nearly $100m Affiliates of Kaiser Permanente have agreed to pay $556 million to resolve allegations that they improperly boosted Medicare Advantage payments over nearly a d...