Matrix Medical Network, a Nashville, Tenn.-based health services company that conducts in-home assessments for Medicare Advantage patients, has agreed to pay $36.5 million to resolve False Claims Act allegations of generating false and invalid diagnoses to artificially inflate risk adjustment payments to its Medicare Advantage clients, the Justice Department said in a June 3 news release.
The government alleged that from 2014 to 2019, Matrix reported unsupported diagnoses of conditions including atrial fibrillation, rheumatoid arthritis and COPD to Medicare Advantage organizations without sufficient clinical information to support them, enabling those insurers to receive inflated capitated payments from CMS. Matrix marketed its services to insurers by advertising its ability to identify diagnoses that would increase risk scores and boost payments — including calculating the estimated “increase in RAF score” from its assessments.
As part of the settlement, Matrix admitted that in numerous instances it reported conditions where its health assessment forms did not contain sufficient clinical information to support the diagnosis. Matrix also entered into a five-year Corporate Integrity Agreement with HHS-OIG requiring annual risk assessments and independent compliance reviews.
Matrix shared the following statment with Becker’s: “Matrix is the largest independent provider of in-home health assessment and care services in the U.S., and our network of board-certified practitioners has served patients for over 25 years. Our independence from insurers and flat-fee business model mean our sole incentive is providing exceptional in-home health assessment and care services that identify unmet needs and improve health outcomes for patients, all in compliance with the laws and regulations governing our industry. These settlements relate to historical documentation practices regarding a discrete set of clinical diagnoses for Medicare Advantage patients that occurred under prior leadership between 2014 and 2019 and alleged conduct at a now-shuttered subsidiary that predated our 2018 acquisition. Since then, we have made meaningful investments in our compliance program and clinical documentation processes to ensure we meet or exceed all CMS and HHS-OIG standards and guidance. We are pleased to move beyond these matters and direct our full attention to providing high-quality patient care.”
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
