A Jacksonville, Fla.-based Medicare Advantage MSO has agreed to pay $14.1 million to resolve False Claims Act allegations of submitting false diagnosis codes to inflate risk adjustment payments, the Justice Department said in an Aug. 3 news release.
Complete Health Partners Holdings, which manages and operates affiliated provider groups in Florida, Alabama and Colorado, allegedly disseminated incorrect coding guidance to coders and physicians and prompted physicians to add unsupported diagnosis codes for drug and alcohol dependence and major depressive and bipolar disorders between 2020 and 2023. Because Complete Health received a percentage of the payments its affiliated MA plans received from CMS, it had a direct financial incentive to inflate beneficiaries’ risk scores.
The case was initiated through a whistleblower complaint filed by a former associate director of risk adjustment at VIVA Health, who will receive approximately $2.47 million from the settlement. The claims are allegations only and there has been no determination of liability.
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