Justice Department goes after one Medicare Advantage executive

Last week, the Justice Department announced it was prosecuting a former executive of HealthSun Health Plans, an insurer offering Medicare Advantage plans in Florida, for engaging in millions of dollars in fraud. There’s no small irony in the fact that our federal government is going after a bit player in the Medicare Advantage fraud world and not prosecuting or cancelling its contract with HealthSun, much less prosecuting and cancelling contracts with the large corporate health insurers that are engaged in billions of dollars of  fraud.

HealthSun’s “prompt voluntary self-disclosure, cooperation, and remediation, as well as HealthSun’s agreement to repay the Department of Health and Human Services’ Centers for Medicare & Medicaid Services (CMS) approximately $53 million in overpayments” clears it of criminal liability, according to the Justice Department. Pretty nice gig. Keep the money when you’re not caught, return it and be absolved of criminal penalty if you are caught.

The Justice Department alleges that Kenia Valle Boza, 39, of Miami, who headed  Medicare Risk Adjustment Analytics at HealthSun, arranged for submission of false and fraudulent information to CMS in order to generate greater income for HealthSun. Lots of HealthSun employees were involved. It’s hard to believe members of HealthSun’s C-suite were unaware. Those executives certainly benefited.

The big problem: The Medicare payment system to insurers offering Medicare Advantage plans is defective. It pays insurers more when they enter more diagnosis codes in patient records and trusts insurers to enter diagnosis codes that are accurate. So, the insurers do what they can to enter as many codes as possible on each enrollee’s medical record. The more codes, the more income to the insurers.

So long as there is a viable case that the codes are accurate, the insurers benefit. And, if the codes are inaccurate, the insurers benefit so long as the government doesn’t perform an audit. Indeed, even when the federal government identifies overcharges in audits, it rarely recoups the overpayments. It’s a great deal for the insurers and the reason they are all chomping at the bit to increase their Medicare books of business.

In the case of HealthSun, Boza and others are charged with fabricating tens of thousands of diagnosis codes and entering them in patient records to generate millions of dollars of overpayments. Let’s hope this is the beginning of a much larger Justice Department crackdown on Medicare Advantage fraud; people with Medicare need protection from the insurance company Medicare Advantage bad actors that they currently are not getting.

Surprisingly and sadly, based on the CMS enforcement actions web page, CMS has not taken a single enforcement action against a Medicare Advantage plan this year, even though several government agencies and independent analysts have reported widespread bad acts by some Medicare Advantage plans.

Here’s more from Just Care:

• CMS overpays Medicare Advantage plans and lets them keep the extra billions
• The government overpays insurers offering Medicare Advantage as much as $140 billion in 2023
• Republicans in Congress “outraged” by billions in Social Security overpayments to vulnerable older adults, silent about overpayments to insurers selling Medicare Advantage plans
• 2023: Five things to think about when choosing between traditional Medicare and a Medicare Advantage plan
• When will the Medicare Advantage scam end?