DaVita Medical Group has agreed to pay $270 million to the Medicare program after identifying suspect billing practices that incorrectly raised its Medicare Advantage payments, says the Department of Justice (DOJ).
The improper MA payments stemmed from actions taken by HealthCare Partners, a large California-based independent physician association acquired by DaVita in 2012.
HealthCare Partners allegedly used tactics like improper coding guidance to gain additional reimbursements from MA. In one example, the DOJ said HealthCare Partners instructed physicians to use improper diagnosis codes for spinal conditions that yielded increased reimbursement from CMS. DaVita then received a share of HealthCare Partners improperly coded payments from Medicare Advantage payers.
DaVita learned of HealthCare Partners’ activity and voluntarily disclosed the provider’s group practices to the government. Law enforcement officials responded by agreeing to a favorable resolution since DaVita cooperated extensively with CMS and the DOJ.
“This settlement demonstrates our tireless commitment to rooting out fraud that drains too many taxpayer dollars from public health programs like Medicare,” said United States Attorney Nick Hanna.
“This case involved illegal conduct in which patients’ medical conditions were improperly reported and were not corrected after further review – all for the purpose of boosting the bottom line. We will continue to pursue and hold accountable any entity that seeks to illegally increase revenue at the expense of the Medicare Advantage so that the program may continue to remain viable for all who need it.”
DaVita’s $270 million settlement also resolves whistleblower allegations of additional reimbursement improprieties.
The whistleblower said that HealthCare Partners purposely added medical diagnoses that providers did not code during chart reviews. HealthCare Partners then submitted falsely coded diagnoses to inflate Medicare payments from their Medicare Advantage payers. HealthCare Partners also ignored inaccurate diagnoses that should have been removed.
The whistleblower will receive $10,199,100 of the DaVita settlement for his cooperation with federal lawmakers.
“DaVita’s alleged conduct was irresponsible and compromised the integrity of the Medicare program,” said Special Agent in Charge Scott J. Lampert of the US Department of Health and Human Services, Office of Inspector General’s New York Region.
“HHS-OIG will continue to ensure that companies that do business with federally funded health care programs do so in an honest fashion.”
OPINION: How Medicare Advantage can help Philly seniors get high-quality medical care | Michael Nutter
For more than 22 years, I served as mayor and a councilperson of Philadelphia. Now, at the age of 61, I have been looking at my AARP newsletters, and listening to my daughter tell me that I'll soon be able to ride SEPTA as a senior for free! I've also been reflective, thinking about next steps, always with the goal of making things better for the people who live and work here. People my age start taking stock of their lives — and asking themselves, "What do I want to do next?"
Many of my fellow baby boomers likely relate to this sentiment – that there is still so much to do, things to accomplish, people to help, more life to experience.
I've been thinking about this constantly since I left City Hall in 2016 and I recently realized that ensuring the most vulnerable in Philadelphia have access to the same kind of high-quality health care that I have should be my focus. While I was in public service, I was passionate about improving our health-care system. The Affordable Care Act made major advancements, but more needs to be done.
In particular, far too many senior citizens in Philadelphia are still struggling with paying their medical bills. Yes, all Americans over age 65 have access to Medicare, but traditional Medicare has many gaps. It doesn't cover dental, vision or hearing – and you have to sign up and pay for Medicare Part D if you want it to include prescription drugs. Then there is the 20 percent coinsurance in traditional Medicare. The costs add up, quickly, especially if you're a senior on a fixed income, or if you're hospitalized.
There is a solution for this dilemma – and it's not complicated: Medicare Advantage. Medicare Advantage is a part of the Medicare system, but it functions much more like employer-based health insurance. Medicare Advantage covers drugs, vision, dental, and hearing, and has an out-of-pocket cap to protect consumers from huge co-pays. In most cases Medicare Advantage plans cost the same or less than traditional Medicare premiums.
The problem is that not enough of our seniors sign up for Medicare Advantage. More than 250,000 people in Philadelphia qualify for Medicare, but only 112,000 – less than half of the eligible population – are on a Medicare Advantage plan. That means nearly 10 percent of Philadelphians aren't getting the most comprehensive health coverage that is readily available to them.
Part of my work in this next phase of my life will be dedicated to spreading the word about the benefits of Medicare Advantage in Philadelphia. To do this, I decided to partner with Clover Health, a health-tech company that operates extensively in New Jersey and is now expanding into Philadelphia.
What makes Clover Health unique, and why I chose to work with them, is how they combine technology with compassion, quality medical care, and a focus on prevention.
They go beyond normal Medicare Advantage, using a high-tech approach to deliver proactive results to their members – keeping them healthy and enjoying their lives. They serve seniors by sending nurse practitioners for in-home visits when they feel a person is at risk of high blood pressure, hasn't taken their medicine, or is having trouble managing their sugar and diabetes.
Seeing the Clover staff in action providing personalized, caring, inclusive and affordable healthcare made it clear to me that they were the right partner for me and for Philadelphia. The timing is also right. Everyone on Medicare is able to switch to a Medicare Advantage plan during the Annual Enrollment Period, which begins Oct. 15.
So, Philadelphia, you may start hearing my voice on the radio or seeing me on TV talking about my new cause. And if you or your parents sign up for our Medicare Advantage plan, then I'll know the message is getting through.
Michael Nutter was the mayor of Philadelphia from 2008 to 2016, and is a senior adviser for Clover Health.