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Whistleblower suit implicates dozens of health plans in Medicare Advantage overpayments

A former medical biller says exaggerated in-home assessments bolstered Medicare reimbursement for payers

More lawsuits targeting Medicare Advantage are rolling in, and the latest calls into question the practices of one company that performed in-home health assessments on elderly patients for 30 health plans in more than 15 states across the country, according to a report from the Center for Public Integrity (CPI).

Although Medicare Advantage has been lauded for its robust plan choice and growing popularity among insurers and consumers, the program has also dealt with criticism concerning as much as $2 billion in overpayments annually. Last month, CPI revealed secret government audits of five health plans indicating Medicare overpaid for more than half of 201 patient claims, totaling $3.3 million.  

In April, at least six whistleblower lawsuits had been filed, targeting Medicare Advantage for inflated risk scores. In the most recent case--filed last year and recently unsealed--a medical billing coder, Becky Ramsey-Ledesma, claimed that Dallas-based CenseoHealth LLC exaggerated in-home assessments to pad Medicare Advantage reimbursement. CenseoHealth "is a valued partner and provider of in-home physician health assessments" that uses a network of nearly 5,000 physicians, according to the company's website.

However, Ramsey-Ledesma alleges that those physicians provided nothing more than a cursory exam and asked a pre-determined list of basic questions. Some of the physicians were not even licensed, she further alleges, and some diagnosed patients merely used their list of prescribed medications, leading to inflated risk scores.

According to CPI, the Centers for Medicare & Medicaid Services investigated the possibility of inflated risk scores tied to in-home assessments in 2013, but later "bowed to industry pressure" and opted against collecting data on physician assessments.

The Texas lawsuit names more 30 insurers including Blue Cross Blue Shield and Humana Inc., according to CPI. In February, Humana revealed it was the subject of a Department of Justice investigation into its Medicare Advantage billing process. The insurer later clarified that it was not the only one under investigation. These concerns surrounding Medicare Advantage risk scores have led two senators to publicly call for further investigation into potentially fraudulent billing practices.

For more:
- read the article

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