�������ýҕ�l

The U.S. Department of Justice has intervened in a lawsuit alleging Sutter Health submitted unsupported diagnosis codes to inflate its Medicare Advantage payments. A whistle-blower accused Sacramento, Calif.-based Sutter and its affiliated medical group, the Palo Alto Medical Foundation, of knowingly submitting unsupported diagnosis codes for certain patients that inflated their risk scores, resulting in higher payments to the providers under the Medicare Advantage program. (Bannow, 12/12)

“Federal healthcare programs rely on the accuracy of information submitted by healthcare providers to ensure that patients are afforded the appropriate level of care and that managed care plans receive appropriate compensation,” said Assistant Attorney General Jody Hunt of the Department of Justice’s Civil Division. “Today’s action sends a clear message that we will seek to hold healthcare providers responsible if they fail to ensure that the information they submit is truthful.” (Anderson, 12/11)

At issue is how Sutter Health and its affiliate Palo Alto Medical Foundation diagnosed patients enrolled in Medicare Advantage, which covers about one-third of Medicare beneficiaries nationwide. The program is funded by the government but offers health plans through private insurers. The lawsuit says Sutter, which has about 48,000 Medicare Advantage enrollees, is liable for at least “hundreds of millions of dollars” in restitution, damages and penalties. The complaint alleges that Sutter submitted unsupported diagnoses, which overstated the medical risk of patients and led to inflated payments. (Young, 12/13)