Background

The U.S. District Court for the Central District of California recently dismissed a complaint-in-intervention filed by the U.S. Department of Justice (DOJ) in U.S. ex rel. Swoben v. Secure Horizons.  As previously reported, in this significant test case, DOJ filed its complaint on May 1, 2017, as to the UnitedHealth Group parties (collectively, UnitedHealth), marking the first time that DOJ joined a whistleblower suit alleging FCA violations regarding Medicare Advantage.  The complaint alleged that the “risk adjustment” payments, which account for the severity of patient conditions as compared to an average Medicare fee-for-service beneficiary, were boosted by ignoring questionable diagnoses.

Continue Reading Dismissal of Medicare Advantage FCA Suit Marks Significant Defeat for Government

The DOJ’s recent complaint-in-intervention in US ex rel. Poehling v. United Health Group—one of two qui tam cases against United Health currently pending in the Central District of California—emphasizes the government’s view that, in order to avoid FCA liability based on allegedly inflated risk adjustment scores for Medicare Advantage members, health plans must follow up on any information they know or have reason to know indicating that providers are submitting or have submitted invalid codes to the health plan.

Continue Reading Second DOJ Complaint: Knowledge of Invalid Codes Requires Follow-Through to Avoid Liability