Humana Found to Ignore Medicare Advantage Fraudulent Billing – Triggering Massive False Claims Act Lawsuit

Our healthcare false claims act attorneys have been closely following a number of managed care organization False Claims Act (“FCA”) cases making their way through the courts.  One of the largest is the Humana, Inc. case which involves a Complaint against one of the biggest Medicare Advantage companies in the U.S.  As background, those who are qualified may receive their Medicare benefits through regular Medicare or a Medicare Advantage Plan (like an HMO or PPO).  Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare.  Then, Medicare pays these companies to cover your Medicare benefits.

In the instance case, a former employee named Olivia Graves is the whistleblower who alleged that Humana recklessly disregarded false billing submitted by Plaza Medical Centers Corp.  Moreover, another allegation states that Humana also disregarded an obligation to return these false billing which turned into overpayments by the government.  First, Humana was supposed to have a Compliance program that would have addressed the fact that Plaza Medical Centers were reporting an unusually sick patient population.  When these go unchecked, the false reporting of sicker patients would result in the government assigning higher risk scores which then effect the “risk adjustment” that the government (CMS) uses to pay the providers and Medicare Advantage insurance plans.    Second, Humana’s knowledge that there were false billing should have triggered an fraud audit and carefully investigating the billing records so that it would not be found to disregard a reverse false claims action – where it is unlawful to retain overpayments beyond 60 days.

As the main enforcement arm of the federal government, the Justice Department reviews all cases filed under the FCA.   Then, once the whistleblower case is assessed, the government decides whether it will step in and prosecute or step back and allow the whistleblower to bring the complaint on the government’s behalf.  Here, the Department of Justice decided to step in and intervene.

The FCA is used to stem out fraud related to billing, staffing, and kickbacks. Examples of these are when financial companies are supposed to abide by state and federal laws and chose to ignore them.  They also bills for services that were not provided or the bill was submitted at an improperly higher rate of reimbursement for the services.  In addition, financial companies are often fount to illegally bill the government for substandard services by fraudulently certifying otherwise. Alternatively, these companies may realize that they have credit from their services that they have to repay to the government, but the companies do not reimburse the government within the 60 day time frame.  See these blogs for more examples of the FCA.

If you witness any potential false claims in California (i.e. requests for reimbursement to the government, not actually rendering work when reimbursement is received, or receiving and knowingly retaining an overpayment) by your company, or you are retaliated against for voicing your concern about potential wrongdoing, immediate action is vital.  Contact the experienced employment law attorneys at Stephen Danz & Associates for a free consultation to discuss your circumstances and legal options.