On July 31, the Department of Justice (DOJ) announced Martin’s Point Health Care Inc. (Martin’s Point), has agreed to pay $22,485,000 to resolve allegations, without admitting or denying the validity of the claims, that it violated the False Claims Act (FCA). According to its website, Martin’s Point is a health care provider with six locations between Maine and New Hampshire with over 1,000 employees and over 90,000 patients.
Alicia Wilbur, a former manager in Martin’s Point’s Risk Adjustment Operations group, blew the whistle on the fraud by filing a civil suit under the qui tam provision of the FCA. Qui tam claims enable private citizens to file lawsuits on behalf of the government if they know of an individual or company defrauding the government. Qui tam whistleblowers are eligible to receive between 15 and 30% of the government’s recovery. Ms. Wilbur will receive approximately $3.8 million as her share of the federal recovery.
The government alleged Martin’s Point, which operates Medicare Advantage plans, performed a chart review of submitted Medicare claims to see if any were missing. The government claimed that many new codes were submitted, but they were not supported by the patients’ charts, which in turn led to higher, fraudulent payments to Martin’s Point.
In the press release, the DOJ notes several quotes, including ones such as “[t]he government expects those who participate in Medicare Advantage to provide accurate information to ensure that proper payments...
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