DOJ Crackdown on Risk Adjustment Fraud & Kickbacks in Medicare Advantage

$249.00 – $255.00

 Original price was: $349.00.Current price is: $249.00.
 Original price was: $399.00.Current price is: $251.00.
 Original price was: $349.00.Current price is: $254.00.
 Original price was: $349.00.Current price is: $255.00.

With the help of whistleblowers, DOJ is actively pursuing or has successfully settled False Claims Act cases alleging risk adjustment fraud against most of the country’s major health insurers, including UHG, Kaiser, Cigna, Humana and Elevance, and has secured more than a dozen settlements. Presenter Mary Inman has represented many of the whistleblowers who have launched these cases, including Dr. Darren Sewell, M.D. in a $32.7M settlement with Freedom Health, Teresa Ross in her up to $100M settlement with Independent Health and founder of now defunct coding vendor DxID, Dr. James Taylor, M.D. in his ongoing case against Kaiser Permanente, and Benjamin Poehling in his ongoing case against UHG. In addition to health insurers, DOJ has also settled these cases with major hospital groups like Sutter Health and vendors who assisted the providers and insurers in submitting diagnoses that were unsupported in order to maximize the beneficiaries risk scores and thereby increase their Medicare reimbursement. This webinar will review these cases to examine the types of allegations that have succeeded and the key decisions in the case law that has been developed in this area. Ms.Inman will also discuss the rise in False Claims Act cases accusing MA Plans and the pharmaceutical and diagnostic companies with whom they contract of paying or receiving illegal kickbacks.

Learning Outcomes:
  • Discuss DOJ’s False Claims Act enforcement efforts under Medicare Part C, including cases alleging risk adjustment fraud and violations of the Anti-Kickback Statute
  • Examine the types of allegations that have been successful in these cases, including “one-way” chart reviews, failure to delete after audits, lack of compliance systems to prevent submission of inaccurate diagnosis codes, pressure or incentives to encourage providers to submit unacceptable diagnosis codes, improper use of physician queries, use of software and vendors leading to unsupported codes, and capturing codes only from in-home assessments without the testing or imaging necessary to reliably diagnose those complex conditions
  • Look at the whistleblowers who launched these cases and the positions they held within the various organizations
  • Review the holdings of the key court decisions arising from these cases
  • Examine the increase in False Claims Act cases alleging that MA Plans and the healthcare companies with whom they contract have violated the Anti-Kickback Statute
Areas Covered in the Session:
  • What is Risk Adjustment
  • Different Types of Risk Adjustment Fraud that have been Alleged
  • DOJ’s Successful Resolutions of Risk Adjustment Fraud FCA Cases and Ongoing Cases to Watch
  • Analysis of Case Law and Key Holdings in this Area
  • What is a Kickback
  • Look at Successful False Claims Act Cases Against MA Plans and Healthcare Companies for AKS Violations
  • Live Q&A Session
Recommended participants:
  • Director of Risk Adjustment
  • Director of Risk Adjustment Revenue Management
  • Medicare Advantage Finance & Risk Adjustment Leader
  • Director of Revenue Management
  • Director of Insurance & Health Data Analysis
  • Director of Medicare Risk Operations
  • Clinical Documentation Integrity & Coding Compliance
  • Clinical Documentation Improvement
Presenter Biography:

Mary Inman, Esq., is a founding partner of Whistleblower Partners, a boutique law firm that specializes in representing whistleblowers worldwide under the U.S. whistleblower reward programs, including the SEC, CFTC, IRS, DOT and FinCEN programs. Mary’s successful efforts to recruit U.K. whistleblowers to file tips under the U.S. whistleblower programs were featured in the New York Times article “Law Firm Sees Britain as Hunting Ground for U.S. Whistleblower Cases.” Her successful representation of three healthcare whistleblowers and the personal toll whistleblowing exacted on these clients was featured in the New Yorker. Mary represents renowned whistleblowers Tyler Shultz (Theranos), Frances Haugen (Facebook/ Meta) and Mark MacGann (Uber) and is a regular commentator on whistleblower matters for the Financial Times, BBC, New York Times, Wall Street Journal, Reuters and Financial News. Over her 27 years in this field, Mary has represented whistleblowers who, while working side-by-side with the Government, have successfully resolved cases alleging customs fraud, risk adjustment fraud, defense fraud and procurement fraud. Mary is also a Founding Board member of Psst. org, a new nonprofit seeking to connect whistleblowers and collectivize the act of speaking out.

Additional Information:

After registration, You will receive an email with login information and handouts (presentation slides) that you can print and share with all participants at your location.

System Requirement:
  • Internet Speed: Preferably above 1 MBPS
  • Headset: Any decent headset and microphone which can be used to talk and hear clearly
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Toll-Free No: +1 800-757-9502
Email: cs@waymoreeducation.com