Dive Brief:
- A Florida physician who filed suit against Humana in 2012 had the case unsealed last month, Louisville Business First reports.
- Dr. Mario Baez contends Humana was complicit in billing fraud perpetuated by his clinic partner and refused to correct the overpayments he reported.
- The issue was around the practice of clinic physicians upcoding the severity of their patients' illnesses to generate higher Medicare Advantage reimbursement.
Dive Insight:
Baez alleges not only did Humana allow the upcoding, but actively encouraged it by providing physicians with information on what diagnoses were “more profitable." The process has major ramifications for CMS, which pays the claims.
According to the Center for Public Integrity, improper billing for Medicare Advantage plans, consisting primarily of upcoding, cost about $70 billion from 2008 to 2013.
Baez is adding to the dicussion by arguing that not only is upcoding a matter of billing fraud but a matter of patient safety, because physicians may adjust their care based on the incorrect belief patients are sicker than they are. He wrote to the presiding judge on the case that even with the right information, caring for seniors is difficult, and that "when medical records are poisoned with misleading data it becomes Russian roulette.”
A question now will be whether the case has any bearing on Aetna's pending aquisition of Humana. If they combine, the pair will be relying on government-sponsored business for about 56% of their total projected $115 billion in annual operating revenue, Lousiville Business First reports.