The Villages Health System has agreed to a $541.5 million settlement to resolve allegations that it submitted false diagnosis codes to secure higher payouts in Medicare Advantage.
The Department of Justice announced the settlement on Wednesday. The case surfaced when TVH made a report in December 2024 through the Department of Health and Human Services Office of Inspector General's self-disclosure protocol, saying it had submitted invalid diagnosis codes to multiple Medicare Advantage organizations.
In the program, these MAOs are paid a fixed amount per month for each of their beneficiaries, which are adjusted for those who are sicker and thus more likely to generate healthcare costs through risk adjustment. Some plans may agree to share with a provider part of what they receive from the Centers for Medicare & Medicaid Services.
Providers in an arrangement like this will receive higher reimbursement for sicker patients, DOJ said in the announcement.
“The Medicare Advantage program relies on accurate diagnoses to protect the federal fisc,” said Assistant Attorney General Brett A. Shumate of the Justice Department’s Civil Division in the press release. “Today’s settlement reflects that we will hold accountable entities that inflate payments through invalid diagnoses."
"At the same time, we will continue to credit organizations that disclose wrongdoing, take appropriate remedial actions, and fully cooperate with the government’s investigation," Shumate said.
The...
DOJ Announces Second DEI-Related False Claims Act Settlement – Deloitte Agrees to Pay $21.5 Million to the United States, plus $2.4 Million to Indiana and Floridaakingump.