FBI investigating Zoom+ for ACA risk adjustment fraud
The FBI has issued a subpoena to Oregon healthcare startup Zoom+. The investigation involves an allegation that Zoom+ “retroactively falsified medical claims to avoid paying” Affordable Care Act risk adjustment payments, reported Axios.
Having younger, healthier members means Zoom+ would need to make risk adjustment payments to offset payers with sicker members. By falsifying medical claims, the company allegedly made members look less healthy so that it wouldn't pay as much for risk adjustment.
Zoom+, which declined to comment to Axios, has dissolved its insurance operations and Oregon has taken its insurance arm into receivership.
Zoom+ has clinics in Portland and Seattle and a health plan in Oregon. The company announced expansion plans in 2016, including on-demand imaging and on-demand access to specialists and announced a “super clinic” that was meant as an alternative to emergency care.
But the startup is dogged by allegations that it has cherrypicked patients and avoided those on Medicare and Medicaid, which pay lower reimbursements than privately insured plans. Avoiding this is the point of the risk-adjustment program, but it has also had quite a rocky road. When the program began it suffered from incorrect estimates of payouts and intake, which meant some payers received less than expected. Lately it has been accused of favoring larger payers and penalizing smaller ones.
The Department of Justice (DOJ) and FBI have continued to turn up the heat on the healthcare industry. The DOJ is involved in two Medicare Advantage claim overpayment cases involving UnitedHealth Group, which has the most members in Medicare Advantage plans. One of the cases claims that UHG overbilled the CMS to the tune of $1 billion by changing diagnosis codes to make patients seem sicker. The DOJ is also investigating other payers as part of the UnitedHealth’s lawsuits.
Last week, EHR vendor eClinicalWorks settled a $155 million False Claims Act case, which was the first False Claims Act involving an EHR vendor. In another False Claims Act case, Freedom Health recently agreed to settle a $31.7 million Medicare Advantage overbilling allegation.
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