BUFFALO, N.Y. (WKBW) — The federal government has filed a claim against Buffalo-based Independent Health for allegedly violating the False Claims Act.
Independent Health is accused of the violation "by submitting or causing the submission of inaccurate information about the health status of beneficiaries enrolled in Medicare Advantage Plans in order to increase Independent Health’s reimbursement."
“The Medicare Advantage Program relies on accurate information about the health status of enrollees to ensure that they receive appropriate treatment and that participating health plans receive proper compensation for the services they actually provide,” said Deputy Assistant Attorney General Michael D. Granston of the Justice Department’s Civil Division. “The department will continue to hold accountable health plans or providers that report unsupported diagnoses to inflate risk adjustment payments.”
“The defendants are alleged to have submitted unsupported diagnosis codes to inflate reimbursements, which enabled them to receive payments from Medicare that were greater than they were entitled,” said U.S. Attorney James P. Kennedy Jr. for the Western District of New York. “Defrauding taxpayer funded health care programs such as Medicare hurts not only taxpayers but our nation’s entire healthcare system.”
Independent Health issued this statement:
"This civil lawsuit, initially brought in 2012 by a former employee of a company in Seattle, Washington for whom DxID provided risk adjustment consulting services, essentially disagreed with DxID's methods of verifying diagnoses in a patient's medical record. After a lengthy investigation, the US Department of Justice had filed a notice of non-intervention. It wasn’t until after Independent Health and DxID filed a motion to dismiss in 2019 that the government filed a motion to intervene, which the court recently granted.
“Independent Health and DxID deny all allegations of wrongdoing in this lawsuit. We will continue defending ourselves vigorously in Court as we believe the coding policies being challenged here were lawful and proper and all parties were paid appropriately. Independent Health and DxID diligently navigate complex and vague coding criteria to ensure that all diagnosis and billing codes properly reflect our Members’ medical conditions and are supported with documentation in the members’ medical records.
“Independent Health has been a leader and highly rated Medicare Advantage Plan for many years. We consistently receive high ratings in member/customer service and have been a 4.5 STAR rated Medicare plan by CMS for years. Top to bottom, from a Board that expects compliant behavior and that we always do what is right for our members and our community, to a compliance department that maintains a strong and independent role, to a disciplined internal audit team composed of experienced professionals and Board accountability, we take this position of trust with the Members we serve with utmost seriousness.”
To read the full complaint, click here.