One of the nation鈥檚 largest dialysis providers will pay $270 million to settle a whistleblower鈥檚 allegation that it helped Medicare Advantage insurance plans cheat the government for several years.
The settlement by HealthCare Partners Holdings LLC, part of giant dialysis company DaVita Inc., is believed to be the largest to date involving allegations that some Medicare Advantage plans exaggerate how sick their patients are to inflate government payments. DaVita, which is headquartered in El Segundo, Calif., did not admit fault.
鈥淭his settlement demonstrates our tireless commitment to rooting out fraud that drains too many taxpayer dollars from public health programs like Medicare,鈥 said U.S. Attorney Nick Hanna in announcing the settlement Monday.
Medicare Advantage plans, which now enroll more than 1 in 3 seniors nationwide, have faced growing government scrutiny in recent years over their billing practices. At least a half-dozen whistleblowers have filed lawsuits accusing the insurers of boosting payments by overstating how sick patients are. In May 2017, two Florida Medicare Advantage insurers agreed to pay nearly $32 million to settle a similar lawsuit.
The DaVita settlement cites improper medical coding by HealthCare Partners from early 2007 through the end of 2014. The company, according to the settlement agreement, submitted 鈥渦nsupported鈥 diagnostic codes that allowed the health plans to receive higher payments than they were due. Officials did not identify the health plans that overcharged as a result.
One such 鈥渦nsupported鈥 code was for a spinal condition known as spinal enthesopathy that was improperly diagnosed in patients in Florida, Nevada and California from Nov. 1, 2011, to Dec. 31, 2014, according to the settlement. The agreement did not say how much health plans took in from the unsupported codes.
The company also contracted with a Nevada firm from 2010 through January 2016 that sent health care providers to visit patients in their homes, a controversial practice that critics have long held is done largely to inflate Medicare payments. These house calls also generated 鈥渦nsupported or undocumented鈥 diagnostic codes, according to the settlement.
Officials said that DaVita disclosed the practices to the government. It acquired HealthCare Partners, a large California-based doctors鈥 group, in 2012. They said the government agreed to a 鈥渇avorable resolution鈥 of the allegations payment because of the self-disclosure.
In a statement, DaVita said the settlement 鈥渞eflects close cooperation with the government to address practices largely originating with HealthCare Partners.鈥 DaVita said the settlement will be paid with escrow funds set aside by the former owners.
鈥淭his case involved illegal conduct in which patients鈥 medical conditions were improperly reported and were not corrected after further review 鈥 all for the purpose of boosting the bottom line,鈥 reads the government鈥檚 statement.
The settlement also resolves allegations made by whistleblower James Swoben that HealthCare Partners knew that many of the diagnostic codes were unsupported, but failed to report them. The company reported only cases in which it deserved higher reimbursement, while ignoring codes that would slash payments, a practice known as 鈥渙ne-way鈥 chart reviews.
Swoben, a former employee of a company that did business with DaVita, will receive just over $10 million for the settlement of the 鈥渙ne-way鈥 allegations, under the federal False Claims Act, which rewards whistleblowers who expose fraud.
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