"When insurance providers take advantage of Medicare and falsely claim that they are entitled to repayment for unsupported diagnoses, American taxpayers suffer in the form of higher costs," stated
Under the Medicare Advantage program, also known as Medicare Part C, Medicare beneficiaries may opt to obtain health care coverage through private insurance plans that are owned and operated by private insurers known as Medicare Advantage Organizations (MAOs). Medicare pays MAOs a fixed, monthly amount to provide health care coverage to Medicare beneficiaries who enroll in their plans. Medicare adjusts these monthly payments to reflect the health status of each beneficiary. In general, Medicare pays MAOs more for sicker beneficiaries and less for healthier ones.
MAOs report beneficiary diagnoses and other information to Medicare on an annual basis and Medicare uses this information to adjust the payments that the MAO receives from Medicare. The settlement resolves allegations that GHC knowingly submitted diagnoses that were not supported by the beneficiaries' medical records to inflate the payments that it received from Medicare.
The settlement resolves allegations originally brought in a lawsuit filed under the qui tam, or whistleblower, provisions of the False Claims Act by
The government's intervention in this matter illustrates its emphasis on combating health care fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement, can be reported to the
This matter was handled by the Civil Division's Commercial Litigation Branch, the
The case is docketed as
The claims resolved by the settlement are allegations only; there has been no determination of liability.