The government has intervened in six complaints that allege members of healthcare coverage provider Kaiser Permanente violated the False Claims Act by submitting inaccurate diagnoses codes, according to a Department of Justice press release.
The complaints involved the government's Medicare Advantage Plan and the alleged scheme was carried out to get higher reimbursements, according to the release.
"Medicare’s managed care program relies on the accuracy of information submitted by health care providers and plans to ensure that patients receive the appropriate level of care, and that plans receive the appropriate compensation," Deputy Assistant Attorney General Sarah E. Harrington of the Justice Department’s Civil Division said in the press release. "Today’s action sends a clear message that we will hold health care providers and plans accountable if they seek to game the system by submitting false information."
The Kaiser Permanente consortium members (collectively Kaiser) are Kaiser Foundation Health Plan Inc., Kaiser Foundation Health Plan of Colorado, The Permanente Medical Group Inc., Southern California Permanente Medical Group Inc. and Colorado Permanente Medical Group P.C. Kaiser is headquartered in Oakland, California, according to the release.
"We are confident that Kaiser Permanente is compliant with Medicare Advantage program requirements and we intend to strongly defend against the lawsuits alleging otherwise," Kaiser Permanente said in a statement to the Northern California Record. "Our medical record documentation and risk adjustment diagnosis data submitted to the Centers for Medicare & Medicaid Services comply with applicable laws and Medicare Advantage program requirements."
According to the Department of Justice press release, Medicare requires that for outpatient medical encounters, diagnoses are submitted only for conditions that required or affected patient care, treatment or management during an in-person encounter in the service year.
The release said that in order to increase its Medicare reimbursements, Kaiser allegedly pressured its physicians to create addenda to medical records after the patient encounter, often months or over a year later, to add risk-adjusting diagnoses that patients did not actually have and/or were not actually considered or addressed during the encounter, in violation of Medicare requirements.
"Our policies and practices represent well-reasoned and good-faith interpretations of sometimes vague and incomplete guidance from CMS. For nearly a decade, Kaiser Permanente has achieved consistently strong performance on Risk Adjustment Data Validation audits conducted by CMS. With such a strong track record with CMS, we are disappointed the Department of Justice would pursue this path," Kaiser Permanente said in the statement.