As the share of Medicare beneficiaries enrolled in Medicare Advantage has steadily grown to over 19 million beneficiaries according to a U.S. Attorney, federal prosecutors intervening in a newly unsealed whistleblower lawsuit in California is yet another example of the government's willingness to protect the integrity of the Medicare Advantage program through the courts.
As reported in Fierce Healthcare, the U.S. Attorney's Office has joined a lawsuit against Sutter Health and the Palo Alto Medical Foundation accusing the health care providers of knowingly submitting wrong or inaccurate diagnosis codes for some Medicare payments. The lawsuit further alleges they violated the federal False Claims Act by submitting inaccurate codes that inflated the "risk scores" of patients on the Medicare Advantage program and enabled Sutter to reap greater reimbursements than entitled from the Centers for Medicare and Medicaid Services, which oversees the Medicare program.
When the Palo Alto Medical Foundation became aware of these inaccurate diagnosis codes, the lawsuit also alleges they failed to identify and delete additional potentially inaccurate codes that would result in a higher payment to Sutter.
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