A Miami woman recently was charged for her role in a long-running Medicare Advantage fraud scheme to defraud Medicare out of tens of millions of dollars.
Kenia Valle Boza, the former director of Medicare Risk Adjustment Analytics at HealthSun, was indicted in Miami federal court for allegedly orchestrating a scheme to submit false and fraudulent information to the Centers for Medicare & Medicaid (CMS) to increase the amount of reimbursement that HealthSun received for certain Medicare Advantage enrollees.
Valle Boza faces six counts — one count of conspiracy to commit healthcare fraud, two counts of wire fraud, and three counts of major fraud against the U.S. The most serious charges carry a maximum sentence of 20 years in prison.
Valle Boza was a certified professional coder, which means she specialized in coding for services performed by physicians and non-physician providers.
How the Scheme Worked
In a Medicare Advantage plan, insurers are paid a fixed amount per patient, which depends in part on the patients’ medical conditions. Certain diagnoses result in higher payments.
Valle Boza and her co-conspirators in this Medicare Advantage fraud scheme, are alleged to have knowingly submitted false and fraudulent information about chronic ailments that Medicare beneficiaries in HealthSun’s plans did not have, and that non-health care providers, such as coders, added to patient health records. This resulted in higher profits for the company and her own compensation, according to court filings.
To accomplish the scheme, she and her co-conspirators allegedly gained access to the login credentials assigned to some physicians to access electronic medical records as the physicians, and fraudulently entered chronic conditions directly into the medical records of beneficiaries.
The diagnoses appeared to have been made by the physicians when, in fact, coders entered the conditions into the beneficiaries’ medical records, often days or weeks after the physician saw them.
It was alleged that between October 2015 and January 2020, Valle Boza and her co-conspirators submitted tens of thousands of false and fraudulent diagnosis codes, resulting in approximately $53 million in overpayments to HealthSun.
Company Not Charged
While she faces charges, it’s important to note that the Justice Department announced that it declined prosecution of HealthSun for several reasons:
- HealthSun’s timely and voluntary self-disclosure of the alleged misconduct.
- The company’s full cooperation in the investigation.
- The company’s remediation, including terminating the employees involved in the alleged misconduct and substantially improving its compliance program.
- HealthSun’s agreement to repay $53 million for payment years 2016-2021.
In declining prosecution of the company, the Department of Justice appears convinced the Medicare Advantage fraud scheme was conducted by a small group of individuals and was not part of a larger corporate healthcare fraud scheme.
Medicare Advantage risk adjustment payment fraud occurs when Medicare Advantage plans report to CMS that their members are sicker than they actually are. This results in CMS overpaying the Medicare Advantage plans for the members.
Such cases are usually prosecuted under the False Claims Act and result in civil liability. This case should serve as a reminder that criminal enforcement can attach to risk adjustment.
Other Similar Allegations
Last year, The New York Times wrote an expose on how major health insurers exploited the Medicare Advantage program to inflate their profits by billions of dollars.
As of March 2023, 65,748,297 people are enrolled in Medicare, an increase of almost 100,000 since the last report in September. Of those: 33,948,778 are enrolled in original Medicare and 31,799,519 are enrolled in Medicare Advantage or other health plans, according to the Center for Medicare Advocacy. So, it’s no surprise that HHS-OIG has designated oversight of managed care as a priority area.
How We Can Help
Physicians, health plans and even those who offer risk adjustment services should look at their processes in place to ensure proper oversight takes place. The Health Law Offices of Anthony C. Vitale can assist clients in creating proper oversight policies to ensure such fraud does not occur. Our firm also can assist if you find yourself the target of an investigation. Give us a call at 305-358-4500, or send an email to firstname.lastname@example.org and let’s discuss how we might be able to assist you.