Matrix will pay $36.5 million to resolve claims in a qui tam action filed in the Southern District of New York. HealthFair will pay $5 million, and Ekbatani will pay $15 million.
Community Care Health Network LLC, doing business as Matrix Medical Network, DPN USA, doing business as HealthFair, and Shahriah ‘James’ Ekbatani have agreed to pay a total of $56.5 million to resolve allegations that they violated the False Claims Act by causing the submission of false or invalid diagnosis codes to the Medicare Advantage programme.
Matrix will pay $36.5 million to resolve claims in a qui tam action filed in the Southern District of New York. HealthFair, which was acquired by Matrix, will pay $5 million, and Mr Ekbatani will pay $15 million to resolve claims in a qui tam action filed in the Eastern District of Texas.
The Medicare Advantage programme, also known as Medicare Part C, allows Medicare beneficiaries to opt out of traditional Medicare and enrol in health plans administered by private insurance companies known as Medicare Advantage Organisations.
The MAOs contract with the Centres for Medicare and Medicaid Services to provide traditional Medicare coverage to beneficiaries enrolled in their plans in exchange for capitated payments. CMS adjusts these capitated payments based on each beneficiary’s health status, as determined by diagnoses submitted by the MAOs.
In general, CMS pays more for sicker beneficiaries, who are likely to incur higher healthcare expenses, and less...
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