Dive Brief:
- 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.
Dive Insight:
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.