By Shelby Livingston
Modern Healthcare, August 21, 2018
Health insurer Anthem has refused to comply with the U.S. Justice Department’s investigation into its Medicare Advantage billing practices, according to federal court documents filed Tuesday.
So the Justice Department this week asked the U.S. District Court for the Southern District of New York to force Anthem to comply with a civil investigative demand issued in March to provide testimony about its chart review and risk-adjustment program for its Medicare Advantage plans.
The Justice Department initially demanded the testimony by April 13 but said Anthem has yet to provide a witness to testify. The court on Monday ordered Anthem to explain why it should not be forced to provide testimony. Anthem has until Sept. 4 to respond.
The Justice Department asked for Anthem’s testimony as part of an investigation into whether Anthem unlawfully obtained hundreds of millions of dollars in Medicare Advantage risk-adjustment payments in violation of the False Claims Act by submitting inaccurate patient diagnosis codes to the CMS.
The feds also want to know if Anthem deliberately disregarded its duty to ensure the diagnosis codes submitted were valid, and asked for testimony about the processes and people Anthem relied on to verify diagnosis codes obtained by providers and through a retrospective chart review.
An Anthem spokeswoman declined to comment.
By Don McCanne, M.D.
Anthem has an opportunity to demonstrate to the Justice Department that they have not been cheating the taxpayers out of hundreds of millions of dollars by upcoding diagnoses of their Medicare Advantage patients, thus qualifying for higher risk adjusted payments based on the fact that their codes indicate that the patients have more costly disorders than they actually have.
If Anthem is innocent, then why does it take the order of a federal court to produce the evidence that would clear them, after failing to comply with an earlier demand? Maybe they are just trying to work the float on the heavy penalties that they know they will eventually have to pay (investing money for their own profit – money that belongs to the taxpayers). Hey, the insurers keep showing us that do know how make a buck off of us, even in a bad situation. And we want to keep them in charge?
Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.