Whistleblower Partners is proud to announce that our client, Teresa Ross, and the United States, have reached a settlement with Independent Health (“IH”), a Medicare Advantage Organization in Western New York, as well as its former subsidiary, DxID, and that subsidiary’s former CEO Betsy Gaffney. The settling parties will pay up to $100 million, with a floor of $36.5 million, depending on Independent Health’s financial performance over the next five years. The settlement amount was based on IH’s ability to pay, with the United States claiming that it was damaged by at least $200 million. Ms. Ross will receive a Relator’s share of 22.5% (up to $22.5 million), reflecting her substantial assistance in the case.

This is the second settlement in Ross’s whistleblower matter. In 2020, Ross, the U.S., and another Medicare Advantage Organization, Group Health Cooperative, reached a $6.375 million settlement to resolve claims that it knowingly inflated the number and severity of patient diagnoses in order to increase risk scores and obtain Medicare Advantage payments to which it was not entitled, a practice known as risk adjustment fraud.

In its case against IH, the government alleged “that Independent Health, DxID and Gaffney violated the False Claims Act 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.”

Medicare Advantage is a managed care alternate system to traditional Medicare. In Medicare Advantage, also called Medicare Part C, the government partners with private insurers and pays them a premium to cover Medicare beneficiaries. The premium payment is generally higher if the beneficiaries have more documented health conditions. As a result, there is an incentive to make patients appear sicklier than they are. To combat this issue, Medicare sets specific rules for medical record documentation and sourcing, and IH, DxID, and Ms. Gaffney are now resolving allegations that they flaunted those rules.

Several Whistleblower Partners attorneys contributed to this matter over the last twelve years, including Mike Ronickher, Mary Inman, and Max Voldman. Our former colleagues Rosie Griffin and Molly Knobler also played significant roles in the case, as well as our co-counsel at Phillips & Cohen LLP and Personius Melber LLP. We are happy to share this important success with our current and former colleagues.

We are also deeply grateful to the substantial efforts of a large Government team over the years of the case, including Bob Trusiak, Peggy McFarland, Kathleen Lynch, David Wiseman, David Coriell, and Samson Asiyanbi.

Mike Ronickher said: “Today’s settlement is historic in two respects. It’s the largest Part C settlement with a health plan purely based on a whistleblower case. It is also one of the first, if not the first, settlements with a vendor for allegations of risk adjustment fraud -- and notably includes an individual executive at the vendor. That’s key for deterrence.”

Max Voldman said: “I’m delighted that Ms. Ross’s courageous whistleblowing and many years of effort have helped the government team recover substantial funds for the Part C program.”

This is the fifth successful settlement in which Whistleblower Partners attorneys have represented whistleblowers alleging risk adjustment fraud.  Whistleblower Partners attorneys continue to pursue similar charges against UnitedHealth Group and Kaiser Permanente, which are poised to be two of the largest intervened risk-adjustment cases in history. We have significant experience representing qui tam relators in healthcare fraud cases. If you would like more information or would like to speak to an attorney at Whistleblower Partners, please contact us for a confidential consultation.