News
Goldberg Kohn is proud to announce that our clients Gloryanne Bryant and Victoria Hernandez are part of a landmark settlement with Kaiser Permanente and various Kaiser subsidiaries to resolve allegations of risk adjustment fraud in two key government programs: the Medicare Advantage program and the Affordable Care Act program. The settlement involving the Medicare Advantage program resulted in the largest False Claims Act settlement ever, resolving allegations of risk adjustment fraud for $556 million. The resolution of our clients’ unique Affordable Care Act claims is, to our knowledge, the first time that a case has been brought, litigated and settled on the basis of risk adjustment fraud in that critical program.
Medicare Advantage, also known as Medicare Part C, is a managed care alternate system to traditional Medicare. In Medicare Advantage, the government partners with private insurers and pays them a premium to cover Medicare beneficiaries. The premium payment is generally higher if the beneficiaries have more documented health conditions, which incentivizes making patients appear sicker than they are. To combat this issue, Medicare sets specific rules for medical record documentation and coding.
Similarly, under the Affordable Care Act, private insurers collect a greater share of the multibillion-dollar insurance pool managed by the government if beneficiaries enrolled with them have more documented health conditions. The government has very similar rules to Medicare, cabining the incentive to falsify health conditions under the ACA. Kaiser Permanente and its subsidiaries are now resolving allegations that they flaunted the rules in both the Medicare and ACA programs.
Ms. Bryant and Ms. Hernandez, longtime senior Health Information Management coding professionals at Kaiser whose responsibilities included risk-adjustment documentation and coding, filed their False Claims Act complaint after Kaiser failed to address the practices at Kaiser that they had identified as allegedly inflating beneficiaries’ risk scores and increasing Medicare reimbursements, and shifting more Affordable Care Act insurance pool funds to Kaiser, without clinical justification.
“Health care coding requires rigorous adherence to guidelines and established rules of accuracy and honesty coupled with specific and truthful documentation,” said Ms. Bryant, who has been one of the country’s foremost experts in clinical coding and documentation for decades. “No patient should be saddled with clinical documentation and diagnoses for conditions they don’t have, and our government programs should not be paying or distributing money based on false documentation and coding.
“Financial pressure should never be allowed to override these basic principles. We filed our complaint when our attempts, over many years, to fix these problems at Kaiser internally were met with silence or even hostility. We are very grateful to Goldberg Kohn for helping us bring these issues to light and ensuring they are taken seriously.”
“Ms. Bryant and Ms. Hernandez went to the government only after years of trying to remedy these problems internally at Kaiser,” added Roger Lewis, partner at Goldberg Kohn. “We are so proud and inspired by their persistence and commitment to justice.”
Our clients’ complaint alleged that Kaiser engaged in systemic and improper Medicare Advantage and Affordable Care Act risk adjustment practices, including adding and retaining diagnosis codes not supported by patients’ medical record documentation and not following coding guidelines, leading to inflated Medicare reimbursements and ACA insurance pool payments to Kaiser.
“Working closely with our clients, we helped develop detailed, technical allegations grounded in their firsthand experiences inside Kaiser’s coding operations,” said Mr. Lewis. “This settlement reflects the importance of relators (whistleblowers) who have a deep understanding of how these systems are supposed to work and when they go awry.”
The settlement resolves cases brought by our clients and other relators. The government joined in a portion of the cases that related to fraud on the Medicare Advantage program. Goldberg Kohn litigated the Affordable Care Act claims without government intervention.
“This settlement underscores that whistleblowers’ firsthand expertise and experience, together with experienced and resourceful lawyering, can result in accountability and justice even against our country’s largest corporations,” said David Morrison, partner at Goldberg Kohn.
Goldberg Kohn’s FCA team included Roger Lewis, David Morrison and Kyle Walther, with critical contributions from paralegal Heidi Smith and now-retired partner Matt Organ.
We are deeply grateful to the efforts of a large Government team who worked on the case over many years, including Laurie Oberembt (who led the team), Braden Civins, Edward Crooke, Gary Dyal, Jonathan Thrope, Michael R. Fishman, Martha Glover, Seth W. Greene, Rachel Karpoff, Michelle Lo, Kevin Traskos, and their current and former colleagues who worked on these matters, including especially Erica Blachman Hitchings. For more information about the United States’ settlement with Kaiser, please see CLICK HERE.
About Us
We have significant experience representing qui tam relators in healthcare fraud cases just like this one and have recovered almost $2 billion for the government in our cases to date. If you would like more information about Goldberg Kohn's False Claims Act practice, call us at 312.863.7222 or contact us online. We are always willing to provide a free, confidential consultation to discuss a potential case.