The DOJ just announced that Martin’s Point Health Care Inc. (Martin’s Point) has agreed to pay $22,485,000 to resolve allegations of violating the False Claims Act.  Martin’s Point operates managed care insurance plans known as Medicare Advantage Plans (MA Plans) for Medicare beneficiaries living in Maine and New Hampshire. Medicare gives beneficiaries the option of enrolling in MA Plans, which generally offer benefits to their original Medicare healthcare plan. MA Plan sponsors receive payments based on their enrolled beneficiaries’ demographic information and diagnoses, referred to as “risk scores.” According to the government, the Maine based health care company submitted diagnosis codes that were not supported by medical records from 2016 to 2019. In turn, the government alleged that Martin’s Point received higher payments from the Centers for Medicare and Medicaid Services, which oversees the Medicare program.

This matter was originally brought under the qui tam provisions of the FCA which allows private citizens to file an action on behalf of the United States. A former manager in Martin’s Point’s Risk Adjustment Operations group, Alicia Wilbur, will receive $3.8 million as part of the resolution.  Deputy Inspector General for Investigations Christian J. Schrank, at the Department of Health and Human Services, Office of Inspector (HHS-OIG), commented that “[i]t is a privilege for health plans to provide services to Medicare beneficiaries, not a right. Medicare Advantage Plan sponsors that submit inaccurate claim information in order to justify inflated payments undermine the financial integrity of the program[…].”

The attorneys at Chilivis Grubman represent clients of all types and sizes in connection to False Claims Act investigations and litigation. If you need assistance with such a matter, please contact us today.