The U.S. Department of Justice (DOJ) recently took an unconventional step by announcing a criminal indictment involving the Medicare Advantage program, moving away from its usual civil enforcement authority under the False Claims Act. This notable shift in approach can be viewed here.
The indictment is focused on the actions of a former employee of a Florida-based company that handles the administration of Medicare Advantage plans. According to the indictment, the individual has been charged with falsifying, and directing others to falsify, diagnosis data submitted to the Centers for Medicare and Medicaid Services (CMS) between 2015 to 2020.
The DOJ’s approach in this instance is a substantial indication that both corporate entities and individuals involved in healthcare program administration should pay extra attention to compliance requirements. The resulting preventive actions may help avoid unwarranted investigations as well as potential criminal and civil penalties.
The Medicare Advantage Program, also known as Part C, offers private health insurance plans as an alternative to Original Medicare. As it stands, these private plans agree to provide enrollees with all Medicare services in exchange for a monthly payment from CMS, an amount that is determined based on the enrollee’s health status and diagnoses.
Under the current indictment, the DOJ alleges that the defendant knowingly submitted inaccurate diagnoses to increase CMS payments to the Florida company, thereby exploiting the Medicare Advantage system for personal and corporate financial gain.
Given that these instances of enforcement are coupled with a significant potential for financial liability, healthcare organizations are well advised to undertake robust and routine compliance assessments to ensure adherence to Medicare requirements.