Several of the nation’s largest insurers have been fleecing the government, a whistleblower claims.
In an opinion published Wednesday, the Ninth Circuit Court of Appeals ruled that there is evidence to suggest that insurers like HealthCare Partners, UnitedHealthCare and Aetna have violated the False Claims Act by manipulating their reporting of patient health data in order to get larger government payments, according to a
National Law Journal report.
The court ruled that whistleblower James Swoben had “adequately alleged that the defendant’s (Medicare) certifications were false and stated a cognizable legal theory under the False Claims Act.”
Swoben, a former employee of health plan provider SCAN, filed the suit in 2009, according to the
National Law Journal. The suit named several insurers that participate in Medicare Part C, or Medicare Advantage.
Medicare Advantage allows qualifying patients to get coverage from a private provider rather than directly though the federal Centers for Medicate & Medicaid Services, or CMS, the
National Law Journal reported. CMS pays insurers a per-enrollee premium, which is calculated by factoring in “risk adjustment data” which can affect the price the government pays.
Swoben alleges that many insurers have designed systems to report only factors that would increase government payments, according to the
National Law Journal. The government intervened and prosecuted SCAN, but not the other defendants in Swoben’s suit. SCAN settled the case in 2012 for about $322 million, the
National Law Journal reported.
A lower court dismissed the case, which Swoben’s attorney says involves more than $1 billion in over-payments. But the Ninth Circuit reversed that decision. Michael Theis, an attorney representing HealthCare Partners, said his clients “respectfully disagree” with the ruling and that the case was baseless.
“The conduct alleged in the complaint is more than 10 years old, the complaint itself was filed under seal prior to DaVita’s merger with HealthCare Partners in 2012, and the complaint was dismissed more than three years ago,” Theis told the
National Law Journal. “The government declined to intervene in the case, and we believe the allegations have no merit.”
While the federal government didn’t intervene in the case, the Justice Department did file an amicus brief with the Ninth Circuit in which it argued that the conduct Swoben alleges does fly in the face of the False Claims Act, the
National Law Journal reported. The DOJ wrote that CMS requires insurers to exercise due diligence to ensure they’re providing accurate data.
“If a plan has not exercised such diligence – especially where it has implemented record-review procedures specifically designed not to reveal unsupported diagnosis codes – the plan’s certification … is ‘false or fraudulent’ under (the False Claims Act,’” the DOJ wrote.
