Sartre Health Agreed to pay 90 million USD To resolve allegations of fraud in its implementation of Medicare Advantage.
The settlement resolved Kathy Ormsby’s claim under the whistleblower clause of the False Claims Act, Kathy Ormsby, a former risk adjustment project manager for the Sacramento Medical System in California. This is the second most reported Medicare Advantage fraud settlement in history. According to Ormsby’s legal team.
The lawsuit was filed in 2015, alleging that Sutter Health deliberately submitted to the Medicare and Medicaid Services Center unsupported diagnostic codes for certain Medicare Advantage beneficiaries. As a result, the health system received exaggerated payments.
In addition, even if Sutter Health was aware of these unsupported codes, according to the lawsuit for government intervention, it did not take sufficient action to correct them.
CMS pays the MA plan per person to provide Medicare-covered services to beneficiaries. The MA plan will generally receive larger payments for beneficiaries with more severe diagnoses. Sutter Health contracted to provide services to certain MA beneficiaries located in California, and received partial payment in exchange.
“The government relies on healthcare providers, including those who provide services to beneficiaries of Medicare Part C, to submit accurate information to ensure proper payment,” Sarah E. Haring, Deputy Assistant Attorney General, Civil Division, Department of Justice He said, In the press release Released on Monday. “Today’s results send a clear message that if healthcare providers deliberately provide or fail to correct untrue information, we will hold them accountable.”
According to a statement posted on the website, the fraud claim was partially resolved in April 2019 at a price of US$30 million. Sutter Health’s websiteThe settlement announced on Monday is a follow-up agreement under which Sartre will pay an additional $60 million to fully resolve the lawsuit. The health system does not recognize any responsibility.
However, as part of the resolution, the health system also signed a corporate integrity agreement or CIA with the Office of the Inspector General of the Ministry of Justice. One of the main requirements of the CIA is that Sutter Health implement a centralized risk assessment program and hire an independent organization to review samples of its MA patients’ medical records and related diagnostic data annually.
“Today’s agreement ends a long-running dispute, enabling Sartre to avoid the uncertainty and further costs of protracted litigation, and to establish a constructive relationship with the government under the leadership of the CIA,” said Sartre. In particular.
According to the whistleblower clause of the False Declaration Act-the act provides that private parties can file a lawsuit on behalf of the United States and obtain part of any recovery-Ormsby is entitled to 15% to 30% of the settlement amount, and her legal team is in a copy The statement said.
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