By Kelly Cloonan
Affiliates of Kaiser Permanente agreed to pay $556 million to resolve allegations that they violated the False Claims Act.
In a 2021 complaint, the U.S. alleged the affiliates submitted invalid diagnosis codes for Medicare Advantage Plan enrollees to receive higher payments from the government, violating rules from the Centers for Medicare and Medicaid Services.
Kaiser owns and operates insurance companies that offer private health plans that Medicare beneficiaries can opt to enroll in instead of traditional Medicare.
Such insurers, known as Medicare Advantage Organizations, are paid a fixed monthly amount for each Medicare beneficiary enrolled in their plans. The payments are based on certain risk factors, and are generally higher for sicker beneficiaries expected to incur higher healthcare costs, the Department of Justice said.
The complaint alleged that Kaiser pressured its physicians to alter medical records after patient visits, adding diagnoses that the physicians had not considered or addressed to drive up its monthly payments.
"Medicare relies on the accuracy of the information submitted by those plans," U.S. Attorney Peter McNeilly for the District of Colorado said. "This resolution sends a clear message that we will hold health care plans accountable if they seek to game the system and pad their profits by submitting false information."
Kaiser did not immediately respond to a request for comment.
Write to Kelly Cloonan at [email protected]
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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...