Pennsylvania-based healthcare insurer Independence Blue Cross has agreed to pay $22.5 million to resolve allegations that it submitted inaccurate diagnosis codes for reimbursement for members covered by its Medicare Advantage plan.
According to a statement from the U.S. Department of Justice, this resulted in the company receiving increased payments from Medicare, in violation of federal law. The complaint was made by a whistleblower suing under protections of the False Claims Act.
Through this alleged act of upcoding, Independence Blue Cross received more in risk-adjusted payments, designed to offset the high costs of chronic illnesses, than it was owed, effectively reporting to the Centers for Medicare & Medicaid Services (CMS) that patients were sicker and more vulnerable than they were in reality.
Part of the complaint made against the insurer was that it failed to withdraw these allegedly inaccurate claims on its own accord, instead certifying to CMS that its determinations were accurate and truthful.
Medicare Advantage, also known as Medicare Part C, is a privatized version of the insurance program, subsidized by the federal government.
“The government pays private insurers over $530 billion each year to care for Americans enrolled in Medicare Advantage,” Assistant Attorney General Brett A. Shumate of the Justice Department's Civil Division, said in a statement. “When insurers knowingly and improperly retain inflated payments based on inaccurate and untruthful...
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