Florida fraud case highlights concerns surrounding Medicare Advantage upcoding

Indictment of a South Florida physician leaves industry scrambling to retain funding despite widespread concerns of inflated risk scores

In what is believed to be the first case of its kind in South Florida, prosecutors are pursuing criminal fraud charges against a physician that overcharged Medicare Advantage plans. The case has pulled the health plan into the spotlight as it attempts to stave off spending cuts, according to the Center for Public Integrity, a nonpartisan news organization.

Prosecutors indicted a Delray Beach physician on eight counts of healthcare fraud linked to a Medicare Advantage plan provided by Humana, according to an FBI statement. The indictment alleges that Isaac Kojo Anakwah Thompson defrauded Medicare by submitting false diagnoses to Humana for Medicare Advantage beneficiaries that resulted in $2.1 million in Medicare payments.

The case raises serious concerns about the overall vulnerability of the Medicare Advantage health plan, according to CPI. Although the indictment does not implicate Humana, the allegations do implicate the risk scores associated with Medicare Advantage plans provided by Humana.

Medicare Advantage reimbursement is different than other plans in that each patient is assigned a risk score. Medicare pays more or less depending on the severity of that score, and Humana passes 80 percent of that fee onto the provider. A Humana spokesperson told the news outlet that it is fully cooperating with the authorities and has already repaid the government.

The case nonetheless shines a light on the potential for improper federal payments when physicians upcode patient records to increase their risk score. In Thompson's case, the physician allegedly submitted phony patient diagnosis, including an abnormal bone disease known as ankylosing spondylitis, a bone inflammation disease known as inflammatory polyarthropathy and major depressive affective disorder.

Previous federal audits show Medicare Advantage risk scores led to $32 billion in overpayments, most of which the government didn't recover, while a previous CPI report found $70 billion in Medicare Advantage overpayments from 2008 to 2013.

Dozens of other federal audits have revealed a dark side to Medicare Advantage health plans, mostly associated with inappropriately rejecting claims. In 2013, the Minnesota attorney general pushed to investigate Humana over claims denials

In November, the Office of Inspector General announced in its latest work plan that it would turn its focus toward Medicare Advantage plans with an impending audit. Meanwhile, CPI notes that the Government Accountability Office is auditing Medicare Advantage billing practices.

Although South Florida is no stranger to fraud, the U.S. Attorney's Office in Miami says this is the first criminal case involving Medicare Advantage plans. It will draw plenty of attention from government officials and advocacy organizations alike, considering Medicare Advantage is fighting President Obama's plan to cut $36 billion over the next decade in an effort to reduce overpayments, as previously reported by CPI.

For more:
- here's the most recent Center for Public Integrity report
- here's the FBI indictment

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