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Largest-Ever Settlement In Medicare “Risk-Score” Manipulation Case

Stories in New York and across the country seem to surface just about every day to underscore — as we note on our health care law website at Daniels, Porco & Lusardi, LLP — that, “Within the health care arena, every legal matter comes with layers of regulatory and compliance issues that must be addressed.”

Like a care provider’s need to scrupulously toe the line regarding the myriad exactions imposed by authorities administering the Medicare and Medicaid programs and state programs modeled on those initiatives, for example.

Although it is difficult for a health care actor to always respond in a timely and completely accurate way to all challenges that routinely arise concerning administrative matters in the health care realm, it is quite easy for an industry participant to get in hot water for failure to do so.

Sometimes it is clearly the case that legal troubles have resulted solely due to a mistake made by a provider — whether a doctor, nurse, pharmacist, facility administrator, billing office or other person/entity.

At other times, civil regulators and/or criminal law enforcers forcefully allege that a care participant has knowingly engaged in some type of health-related wrongdoing that unlawfully inflates profits and defrauds the public.

Such was the case recently with what has been described as the largest civil settlement yet reached in the United States concerning a whistleblower case involving health care insurance companies that manipulated so-called “risk scores” of patients. Authorities say that such manipulation by two insurers — achieved with tampered billings that inflated charges through false treatment accounts and other deceptive acts — yielded spiked payments in the many millions of dollars.

Those companies are now tasked with repayment of nearly $32 million to settle the claims against them.

Risk-score fraud and related overbilling is firmly on the radar scope of regulators and government auditors currently. Individuals and businesses targeted in investigatory probes alleging such illegality might reasonably want to timely secure diligent legal representation from a law firm that routinely advocates on behalf of health care actors in civil and criminal matters alleging medical-related fraud.


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