Insurance company settles allegations involving inaccurate Medicare diagnosis codes and payments.
Independence Blue Cross has agreed to pay $22.5 million to settle allegations that it improperly kept extra Medicare payments tied to inaccurate patient diagnosis information, according to the U.S. Department of Justice (DOJ). The settlement involves claims that the Pennsylvania insurance company did not correct certain diagnosis codes after medical record reviews failed to support them. The case involves Medicare Advantage, the private insurance program also known as Medicare Part C. Under the program, the federal government pays private insurance companies a monthly amount for each enrolled patient. The amount can change based on a patient’s health needs. Patients with more serious medical conditions generally result in higher payments because they are expected to require more medical care.
To determine those payments, the Centers for Medicare & Medicaid Services (CMS) collects information about patients’ medical conditions from insurance companies. Diagnosis codes are used as part of that process. The government alleged that some of the information submitted by Independence Blue Cross, also known as IBX, was not supported by the patients’ medical records.
The DOJ said IBX ran a chart review program between 2017 and 2021. Nurses reviewed patient records to find medical conditions that were supported by the records. The company then used the findings to submit additional diagnosis codes to Medicare and seek higher payments. According to the allegations, however, the reviews also found cases in which diagnosis codes that IBX had already reported were not supported by the medical records. Instead of removing those codes and returning the related payments, the government alleged that the company left them in place.
The government said this created an uneven process in which the company used chart reviews when they supported additional payments but did not take the same action when the reviews showed that previous payments were too high. The DOJ alleged that IBX also certified to the government that its submitted information was accurate and truthful. IBX’s settlement resolves the allegations without a finding of liability. The company agreed to pay the $22.5 million amount rather than continue fighting the claims through the court process.
The case began as a whistleblower lawsuit brought under the False Claims Act. That federal law allows private individuals with information about possible false claims against the government to file lawsuits on the government’s behalf. If money is recovered, the person who brought the case may receive part of the payment. The whistleblower in this case was a former IBX employee. Under the settlement, that person will receive $3.825 million from the recovery. The case was filed in the U.S. District Court for the Eastern District of Pennsylvania under the name United States ex rel. Crawford v. Independence Blue Cross.
Federal officials said the case is part of ongoing efforts to address suspected fraud involving government health programs. Medicare Advantage has become a major part of the U.S. health care system, with the government paying hundreds of billions of dollars each year to private insurers providing coverage through the program. The settlement also comes as federal officials have placed greater attention on fraud, waste, and improper spending involving government programs. The DOJ said False Claims Act cases remain an important way to recover government funds when companies are accused of submitting false information or keeping payments they were not entitled to receive.
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Independence Blue Cross to Pay $22.5M to Resolve False Claims Act Allegations
