Posted on Sep 14, 2021
Data Mining Helped Medicare Advantage Plans Commit Fraud, Justice Department Alleges
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https://www.npr.org/sections/health-shots/2021/09/14/ [login to see] /medicare-advantage-fraud-data-mining
The Justice Department has accused an upstate New York health insurance plan for seniors, along with a medical analytics company the insurer is affiliated with, of cheating the government out of tens of millions of dollars.
The civil complaint of fraud, filed this week, is the first by the federal government to target a data mining company for allegedly helping a Medicare Advantage program to game federal billing regulations in a way that enables the plan to overcharge for patient treatment.
The lawsuit names as defendants the medical records review company DxID and Independent Health Association, of Buffalo, which operates two Medicare Advantage plans. Betsy Gaffney, DxID's founder and CEO, also is named in the suit. DxID, which shut down in August, is owned by Independent Health through another subsidiary.
The Justice Department has accused an upstate New York health insurance plan for seniors, along with a medical analytics company the insurer is affiliated with, of cheating the government out of tens of millions of dollars.
The civil complaint of fraud, filed this week, is the first by the federal government to target a data mining company for allegedly helping a Medicare Advantage program to game federal billing regulations in a way that enables the plan to overcharge for patient treatment.
The lawsuit names as defendants the medical records review company DxID and Independent Health Association, of Buffalo, which operates two Medicare Advantage plans. Betsy Gaffney, DxID's founder and CEO, also is named in the suit. DxID, which shut down in August, is owned by Independent Health through another subsidiary.
Data Mining Helped Medicare Advantage Plans Commit Fraud, Justice Department Alleges
Posted from npr.org
Insurance
DOJ
Fraud
Medical
Health
Posted >1 y ago
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PO1 William "Chip" Nagel
..."Medicare Advantage plans are paid more for "sicker" patients
The Centers for Medicare & Medicaid Services, or CMS, pays the health plans using a complex formula called a "risk score," which is intended to render higher rates for sicker patients and less for those in good health. The data mining company combed electronic medical records to identify missed diagnoses — pocketing up to 20% of new revenue it generated for the health plan."...
..."Medicare Advantage plans are paid more for "sicker" patients
The Centers for Medicare & Medicaid Services, or CMS, pays the health plans using a complex formula called a "risk score," which is intended to render higher rates for sicker patients and less for those in good health. The data mining company combed electronic medical records to identify missed diagnoses — pocketing up to 20% of new revenue it generated for the health plan."...
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