A New Medicare Advantage Fraud Case Is Taking Aim At Data Mining : Shots - Health News - NPR

A civil suit filed by the Justice Department this week links exaggerated patient bills to tens of millions of dollars in overcharges by Medicare Advantage plans.

A civil suit filed by the Justice Department this week links exaggerated patient bills to tens of millions of dollars in overcharges by Medicare Advantage plans.

The lawsuit names as defendants the medical records review company DxID and Independent Health Association, of Buffalo, which operates two Medicare Advantage plans.

The DOJ complaint expands on a 2012 whistleblower suit filed by Teresa Ross, a former medical-coding official at Group Health Cooperative in Seattle, one of the nation's oldest and most prestigious health plans.

For instance, Ross alleged that the plan billed for "major depression" in a patient described by his doctor as having an "amazingly sunny disposition." Group Health, now known as the Kaiser Foundation Health Plan of Washington (a company unrelated to Kaiser Health News or the Kaiser Family Foundation), denied wrongdoing.

Now the Justice Department is taking over the case and targeting DxID for its work on behalf of both Group Health and Independent Health.

In the legal complaint filed Monday, the Justice Department alleges that Gaffney pitched DxID's revenue-generating tools as "too attractive to pass up.".

While popular with seniors, Medicare Advantage has been the target of multiple government investigations, Justice Department and whistleblower lawsuits and Medicare audits

In July, the Justice Department consolidated six such cases against Kaiser Permanente health plans