Kenia Valle Boza, former director of Medicare risk adjustment analytics at HealthSun, which operates Medicare Advantage plans in South Florida, allegedly orchestrated a scheme to submit false information to CMS to increase the amount that HealthSun received, according to an Oct. 26 news release from the Justice Department.
Ms. Valle and her co-conspirators allegedly entered and caused others to enter diagnoses based on tests that were not a proper basis for diagnosing conditions. She also allegedly gained access to electronic medical records assigned to certain physicians and falsely entered chronic conditions.
Ms. Valle is charged with one count of conspiracy to commit healthcare fraud and wire fraud, two counts of wire fraud and three counts of major fraud against the United States.
The Justice Department, meanwhile, has declined prosecution of HealthSun because of the organization’s voluntary self-disclosure and agreement to repay $53 million in overpayments, the release said.
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