In a significant development, Independent Health Association, a health insurance provider based in Buffalo, New York, along with the CEO of its medical analytics subsidiary, DxID, have agreed to pay up to $100 million to settle allegations of fraudulent billing practices in their Medicare Advantage plans.
The U.S. Department of Justice (DOJ) accused Independent Health and DxID of inflating claims by submitting exaggerated or nonexistent diagnoses, thereby receiving higher reimbursements from Medicare. The settlement includes a guaranteed payment of $34.5 million, with the potential total reaching $100 million, depending on the company’s financial performance over the next few years. Notably, neither party admitted to any wrongdoing as part of the settlement.
This case originated from a whistleblower lawsuit filed by Teresa Ross, a former medical coding professional, who alleged that the companies engaged in practices leading to substantial overpayments from Medicare. As a result of her role in exposing the fraud, Ross will receive at least $8.2 million from the settlement.
The settlement underscores the federal government’s commitment to addressing fraudulent activities within Medicare Advantage programs, which currently serve over 33 million beneficiaries nationwide. Michael Granston, a DOJ deputy assistant attorney general, emphasized that this outcome sends a clear message to the Medicare Advantage community about the consequences of submitting inflated claims.
As Medicare Advantage plans continue to grow in popularity, this case highlights the importance of vigilance and integrity in billing practices to ensure the sustainability and fairness of the Medicare system.
For more details, read the full article on KFF Health News.
