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Kaiser to spend more than $6 million in false claims settlement

by John R. Fischer, Senior Reporter | November 20, 2020
Kaiser Foundation Health Plan of Washington will pay over $6 million to settle allegations that a company it acquired submitted invalid diagnoses to Medicare
Kaiser Foundation Health Plan of Washington will pay $6,375,000 to settle False Claims allegations against it.

The accusations refer to Group Health, a company acquired by parent company Kaiser Permanente in 2017. Group Health is alleged to have submitted invalid diagnoses to Medicare for Medicare Advantage beneficiaries in exchange for flat rate payments from Medicare. Kaiser Permanente denies this.

“We’ve fully cooperated with the Department of Justice throughout this entire process and have agreed to a settlement to resolve the outstanding civil claims, as we believe Group Health submitted its data in good faith and in reliance on recommendations by its contracted risk adjustment vendor, which purported to be an expert in this area," Kaiser Permanente told HCB News in a statement.

The case is docketed as United States ex rel. Teresa Ross v. Group Health Cooperative, Independent Health Association, Independent Health Corporation, DxID LLC, Elizabeth Gaffney, and John Haughton, M.D., No. 12-CV-0299S (W.D.N.Y.).

The accusations were brought forth by Teresa Ross, a former employee of Group Health Cooperative. She alleges that GHC knowingly submitted diagnoses in 2011 and 2012 to increase Medicare payments even though they were not supported by the medical records of beneficiaries. She will receive approximately $1,500,000.

Medicare pays Medicare Advantage Organizations (MAOs) a fixed, monthly amount for healthcare coverage for Medicare beneficiaries who enroll in their plans. It generally pays MAOs more for sicker beneficiaries than healthier ones. MAOs report beneficiary diagnoses among other information to Medicare annually, which Medicare uses to adjust payments that it provides to MAOs.

“We will continue to pursue those who undermine the integrity of the Medicare program and the data it relies upon, said Assistant Attorney General Jeffrey Bossert Clark of the department of Justice’s civil division in a statement.

The claims resolved are allegations only and hold no determination of liability.

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