- The Department of Justice is intervening in six lawsuits that allege Kaiser Permanente submitted inaccurate diagnosis codes in order to receive higher reimbursement from the Medicare Advantage program.
- The suits allege Kaiser pressured physicians to add diagnoses to patient medical records — diagnoses they did not actually have — to boost patient risk scores to land higher payments. These records were allegedly altered months or up to a year later, the DOJ said.
- The six lawsuits were brought by whistleblowers, in one instance a Kaiser data employee, and maintain Kaiser violated the False Claims Act.
The government spends billions of dollars on the Medicare Advantage program each year as more seniors turn to the program over traditional Medicare coverage.
But a seemingly perennial issue in the program is plans attempting to game the system to secure higher payments.
MA plans are paid on a per-member basis. Those payments are then adjusted to reflect the acuity or severity of the patient's health status. Typically, the sicker a member is, the higher the reimbursement.
A recent report found that $2.6 billion was spent on diagnosis codes that were unjustified. It's a problem federal regulators are concerned about, and attempting to keep a close watch on.
"Today's action sends a clear message that we will hold health care providers and plans accountable if they seek to game the system by submitting false information," DOJ said in a statement.
Kaiser Permanente operates one of the largest MA plans by membership, according to the Kaiser Family Foundation. Overall, Kaiser has a 7% market share in the MA program, trailing giants like UnitedHealthcare, Humana, Blue Cross Blue Shield plans and CVS Health.
Kaiser Permanente did not immediately respond to a request for comment.