A Maine-based healthcare provider will pay nearly $22.5 million to settle allegations it violated the False Claims Act by knowingly submitting inaccurate diagnosis codes for Medicare enrollees to increase reimbursements.
Martin’s Point Health Care, which operates Medicare Advantage plans for beneficiaries living in Maine and New Hampshire, allegedly submitted risk scores for patients that did not match their medical records, the Department of Justice (DOJ) said in a press release Monday.
The settlement resolves a lawsuit brought under the qui tam provisions of the False Claims Act by Alicia Wilbur, a former manager in the risk adjustment operations group at Martin’s Point. Wilbur will receive approximately $3.8 million.
The settlement is believed to be the largest in Maine under the False Claims Act, according to an emailed statement from Wilbur’s representatives at law firm Phillips & Cohen.
The details: Between 2016 and 2019, Martin’s Point operated a chart review program that retained vendors and employed healthcare coders to review medical records, according to the settlement agreement.
During the relevant period, Martin’s Point relied on results from its chart reviews to submit additional diagnosis codes to Medicare that the healthcare provider had not reported, per the DOJ. This included codes “unsupported, unsubstantiated, and invalid based on the underlying medical records,” the settlement agreement stated. The DOJ alleged Martin’s Point submitted these fraudulent codes knowingly and thus received improper payments from the government.
The settlement “sends a clear message to the Medicare Advantage community that the United States will take appropriate action against those who knowingly submit inflated claims for reimbursement,” said Deputy Assistant Attorney General Michael Granston of the DOJ’s Civil Division in the agency’s release.
Martin’s Point did not respond to a request for comment.
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