The impact of the Department of Justice’s (DOJ) voluntary self-disclosure program was on display in the agency’s declination of an enforcement action against Florida-based health insurance company HealthSun Health Plans for apparent fraud committed by its employees and agents.
HealthSun’s legal representatives received a declination letter from the DOJ’s Fraud Section dated Oct. 25, in which the agency said it would not prosecute the company regarding the apparent fraud. The determination took into consideration multiple factors, including HealthSun’s agreement to repay approximately $53 million to the Department of Health and Human Services’ Centers for Medicare & Medicaid Services (CMS) found to have been obtained because of the alleged scheme.
The details: The DOJ said the scheme was orchestrated by HealthSun’s former director of Medicare risk adjustment analytics, Kenia Valle Boza. On Oct. 26, Valle was charged by the agency with one count of conspiracy to commit healthcare fraud and wire fraud, two counts of wire fraud, and three counts of major fraud against the United States.
From 2015-20, the DOJ found Valle and her unnamed coconspirators submitted false and fraudulent information to the CMS to increase the amount of payment HealthSun received for its Medicare Advantage enrollees.
Compliance considerations: The DOJ has touted changes to its voluntary self-disclosure policy made earlier this year as a way for companies to earn greater incentives for coming forward with information regarding apparent corporate misconduct. Declinations are among potential benefits offered by the agency.
HealthSun and its corporate parent, Elevance Health, were lauded by the DOJ for their timely disclosure. The companies cooperated fully with the agency and will continue to cooperate in its ongoing investigation into the apparent scheme. HealthSun terminated the employees involved, reported and corrected the false information submitted to the CMS, and improved its compliance and internal controls regarding its Medicare Advantage program.
“Following the acquisition of HealthSun (in 2017), we discovered this conduct, launched an investigation immediately, and remediated the issues,” said an Elevance Health spokesperson in an emailed statement. “HealthSun and Elevance Health have best-in-class compliance programs and actively work to detect and address acts of misconduct. We have been engaged with federal law enforcement and will continue to fully cooperate with the ongoing investigation.”
Editor’s note: This story was updated Nov. 2 to include comment from Elevance Health.