A recent twenty-two million dollar settlement agreement between the federal government and Martin’s Point[1] tells a familiar story of alleged Medicare Advantage (“MA”) risk adjustment upcoding by a Medicare Advantage Organization (“MAO”). In a recently unsealed False Claims Act (“FCA”) Complaint, the federal government alleged that Martin’s Point, an MAO, had “dedicated an entire internal unit and hired third party vendors to capture codes that physicians may have missed. Under the guise of promoting accuracy, charts were scoured, physicians were paid $100 to complete questionnaires and members were paid $25 to be re-examined. [Further, t]o maximize Medicare payments in the retrospective funding year, Martin’s point hired coders and contractors to review medical charts to capture additional diagnosis codes.” Id. (Emphasis supplied). Given the size of the settlement, both MAOs and providers would be wise to study the offending arrangement described in the Complaint, in addition to the so-called “Covered Conduct” outlined in the settlement agreement.
Among other things, the alleged “Covered Conduct” described in the July 2023 settlement agreement alluded to what was, undoubtedly, the unwitting assistance in the alleged scheme of the providers from whom the medical charts at issue derived. Specifically, the settlement agreement noted that Martin’s Point’s “chart review” program “retrieved medical records (also known as charts) from healthcare providers documenting services they had rendered to Medicare beneficiaries enrolled in Martin’s Point’s MA plans.” The line between lawful and unlawful chart review methods in the risk adjustment space can be a difficult one to navigate – both MAOs and providers must tread carefully when engaging in the process, particularly when third party vendors are involved.
Ultimately, it does not appear that the providers who worked with Martin’s Point were themselves pursued by the government. But they very well could have been, as the government has pursued FCA actions for alleged risk adjustment fraud against both MAOs and providers alike.[2] For this reason, it is critical that physicians question any MAO or MAO-vendor that seeks to pressure or incentivize the re-evaluation of medical charts or, as was allegedly the case here, the re-evaluation of patients for the purpose of increasing or modifying diagnosis coding for the patient. Such requests for chart reassessments or chart “refreshing[3]” may not be as benign as sound.
How Frier Levitt Can Help
Frier Levitt has considerable experience in the Medicare Advantage risk adjustment space, including Qui Tam whistleblower litigation. Should your MAO’s chart review requests raise any red flags, contact Frier Levitt for a consultation.
[1] The settlement agreement also included Martin’s Point Health Care, Inc.’s subsidiary, Martin’s Point Generations Advantage, Inc. (both entities, collectively, “Martin’s Point”). Per its terms, the Settlement Agreement was “neither an admission of liability by Martin’s Point nor a concession by the United States that its claims [we]re not well-founded.” A copy of the settlement agreement is available here: https://www.justice.gov/media/1308116/dl?inline.
[2] See, e.g., https://www.justice.gov/usao-sdfl/pr/doctor-who-falsely-diagnosed-hundreds-patients-part-medicare-fraud-scheme-sentenced
[3] Frier Levitt has previously written about the issue of chart refreshing in the MA risk adjustment space. See https://www.frierlevitt.com/articles/refreshing-a-risk-adjustment-coding-practice-to-be-avoided-by-providers-in-medicare-advantage-contracts/
