- A federal appeals court overturned a lower court decision denying a whistleblower’s right to file an additional amended complaint, allowing the false claims lawsuit against Medicare Advantage organizations to advance.
- The Ninth Circuit Court of Appeals ruling resurrects James Swoben’s charge that UnitedHealthcare, Aetna, WellPoint, Health Net, and HealthCare Partners submitted false certifications based on biased retrospective medical record reviews designed not to identify erroneously reported diagnosis codes.
- CMS requires Medicare Advantage organizations to certify their data to ensure they don’t benefit financially from submitting erroneous codes.
According to the complaint, the companies submitted false diagnosis codes beginning in 2005 with the aim of increasing their Medicare Advantage payments. Swoben alleged the organizations were on notice that CMS was monitoring their data for possible violations.
In Wednesday’s opinion, the court said Swoben’s proposed amendment should be allowed as it adequately identifies “the who, what, when, where, and how of the misconduct charged.”
Swoben brought another qui tam lawsuit against his former employer, SCAN Health Plan, Modern Healthcare reports. That case ended with SCAN paying the government $320 million. Swoben didn’t reap any reward because he wasn’t the original source of the charges brought against his former employer.
Under the Medicare Advantage program, the government pays participants a fixed monthly rate for each enrollee. However, those payments may be adjusted to reflect the health status of a company’s enrollees.