Potential Whistleblowers: How Misconduct in Medicare Advantage Plans Drives Overpayments and Affects Care Quality

A recent federal government report on Medicare Advantage (MA) plans reveals a concerning issue: billions of dollars are being funneled into MA companies through inflated, risk-adjusted payments based on questionable diagnoses. This situation not only drains taxpayer dollars but also raises potential issues in patient care and program integrity. If you're aware of specific misconduct related to these practices, you may have an opportunity to act under the False Claims Act (FCA) to address fraud and support accountability.

Key Findings of the OIG Report

The October 2024 report from the Office of the Inspector General (OIG) for the United States Department of Health and Human Services highlights how MA plans and their associated practices led to an estimated $7.5 billion in inflated payments for 2023 alone. This misuse is driven by health risk assessments (HRAs) and HRA-linked chart reviews.

HRAs and HRA-linked chart reviews are two mechanisms that MA plans use to identify diagnoses, generally for the purpose of increasing risk-adjusted payments MA plans receive from the government. An HRA is a questionnaire that collects health-related information from a patient—including their medical history, lifestyle, and other relevant health information—typically during an annual wellness visit. Chart reviews refer to the process by which private Medicare Advantage plans review patient charts to identify additional conditions that are not present in claims data. An HRA-linked chart review is a chart review that relies solely on an HRA as the source of additional diagnoses.

Both HRAs and HRA-linked chart reviews have come under scrutiny for the following reasons:

  1. Unsupported Diagnoses: Diagnoses recorded only through HRAs or HRA-linked chart reviews led to inflated payments. Many of these assessments occurred in non-traditional settings, such as enrollees' homes, and often by third-party vendors rather than patients’ primary care providers.
  2. Concentration Among Certain Companies: Just 20 MA companies accounted for 80% of these risk-adjusted payments, despite covering only half of all enrollees. This disparity raises questions about whether these organizations systematically overuse HRAs and chart reviews to capture inflated payments.
  3. Focus on Serious Health Conditions: Payments were frequently based on diagnoses of chronic, serious conditions, like congestive heart failure or diabetes, which require consistent, comprehensive care. However, many patients with these diagnoses had no other recorded services, raising concerns about either the validity of these diagnoses or the care patients received.

Risks of MA Practices on Patient Care and Data Integrity

These findings underscore three serious concerns:

  1. Patient Care and Access to Services: MA companies should use HRAs to connect enrollees with appropriate care. However, in many cases, patients whose diagnoses are drawn from HRAs may not be receiving necessary follow-up care, potentially undermining their health and raising the specter discussed in point 3 below that the true purpose of the HRAs may solely have been mining for lucrative diagnoses that risk adjust.
  2. Data Accuracy and Program Integrity: Accurate data collection and reporting are vital to the success of the Medicare Advantage program. When MA companies report unsupported diagnoses, it distorts the data used to determine health needs, impacting funding allocations and program decisions.
  3. Improper Financial Incentives: The structure of MA payments, which increases based on an enrollee's health risks, can create incentives to overstate the severity of patient health issues. This practice not only results in taxpayer losses but also may mask the true cost and care needs of the population.

Your Role as a Whistleblower

If you possess knowledge of these practices within an MA organization, you could play a significant role in holding these companies accountable. The False Claims Act allows private individuals to sue on behalf of the government to recover fraudulently obtained funds. As a whistleblower, you might help:

  • Expose Fraudulent Billing Practices: By reporting unsupported diagnoses and inflated HRA submissions, you could help to reduce improper payments and hold companies accountable.
  • Protect Enrollees' Rights to Proper Care: If a company focuses on maximizing payments rather than providing adequate care, whistleblowers can advocate for patients who are neglected in favor of profit.
  • Preserve Program Integrity: Whistleblower actions contribute to more accurate data collection, program integrity, and cost control, ultimately benefiting Medicare and taxpayers.

Legal Protections and Incentives for Whistleblowers

The False Claims Act provides whistleblowers with legal protections against retaliation from employers. Additionally, whistleblowers may be entitled to a portion of the recovered funds, which can be substantial, particularly in cases involving billions of dollars in improper payments.

Final Thoughts

As a potential whistleblower, you have a unique opportunity to support fair and accurate healthcare practices. This recent OIG report has uncovered significant misconduct that may present grounds for action.

The attorneys at Whistleblower Partners have significant experience representing qui tam relators in healthcare fraud cases and have developed unparalleled expertise as it relates to whistleblowers exposing MA plans, hospitals, provider groups and vendors for alleged manipulation of risk scores, known as “risk adjustment fraud.” Our attorneys have successfully represented whistleblowers in settlements with Freedom Health, Sutter Health, and Kaiser Foundation Health Plan of Washington (formerly known as Group Health Cooperative) and continue to work hand-in-hand with the Department of Justice on ongoing cases against United Health Group, Kaiser Permanente and Independent Health Association. If you would like more information or would like to speak to an attorney at Whistleblower Partners, please contact us for a confidential consultation.