{"id":13862,"date":"2024-12-24T07:36:14","date_gmt":"2024-12-24T07:36:14","guid":{"rendered":"https:\/\/distilinfo.com\/healthplan\/?p=13862"},"modified":"2024-12-24T07:36:14","modified_gmt":"2024-12-24T07:36:14","slug":"medicare-fraud-settlement-hits-independent-health","status":"publish","type":"post","link":"https:\/\/distilinfo.com\/healthplan\/medicare-fraud-settlement-hits-independent-health\/","title":{"rendered":"Medicare Fraud Settlement Hits Independent Health"},"content":{"rendered":"<h1 class=\"font-600 text-2xl font-bold\">Medicare Fraud Settlement Hits Independent Health<\/h1>\n<h2 class=\"font-600 text-xl font-bold\">Settlement Overview<\/h2>\n<p class=\"whitespace-pre-wrap break-words\">Independent Health faces a massive $98 million settlement over Medicare Advantage fraud allegations involving its former subsidiary, DxID. The settlement addresses claims of systematic diagnosis code manipulation aimed at increasing government reimbursements.<\/p>\n<h2 class=\"font-600 text-xl font-bold\">Fraudulent Activities Exposed<\/h2>\n<p class=\"whitespace-pre-wrap break-words\">DxID, which ceased operations in 2021, allegedly conducted retroactive medical record searches to artificially inflate Medicare Advantage enrollees&#8217; risk scores. Their services extended beyond Independent Health, offering similar coding assessment services to other health plans.<\/p>\n<h2 class=\"font-600 text-xl font-bold\">Whistleblower&#8217;s Role and Compensation<\/h2>\n<p class=\"whitespace-pre-wrap break-words\">Teresa Ross, a former Group Health Cooperative employee, exposed the fraudulent practices through a whistleblower lawsuit. Her actions will result in a minimum $8.2 million compensation from the settlement. Additionally, DxID&#8217;s former CEO, Betsey Gaffney, has agreed to pay $2 million.<\/p>\n<h2 class=\"font-600 text-xl font-bold\">Settlement Structure<\/h2>\n<p class=\"whitespace-pre-wrap break-words\">The agreement includes:<\/p>\n<ul class=\"-mt-1 [li&gt;&amp;]:mt-2 list-disc space-y-2 pl-8\">\n<li class=\"whitespace-normal break-words\">Guaranteed payments of $34.5 million<\/li>\n<li class=\"whitespace-normal break-words\">Potential additional payments up to $63.5 million based on payment ability<\/li>\n<li class=\"whitespace-normal break-words\">No admission of wrongdoing from Independent Health<\/li>\n<\/ul>\n<h2 class=\"font-600 text-xl font-bold\">Industry-Wide Context<\/h2>\n<p class=\"whitespace-pre-wrap break-words\">The case highlights a broader issue within Medicare Advantage, as numerous major plans have faced similar upcoding allegations. These practices involve making patients appear sicker on paper to secure higher government reimbursements.<\/p>\n<h2 class=\"font-600 text-xl font-bold\">Company Response<\/h2>\n<p class=\"whitespace-pre-wrap break-words\">Independent Health, a Buffalo-based nonprofit insurer, maintains that the settlement allows them to avoid prolonged litigation costs and uncertainty. They emphasize that the dispute didn&#8217;t affect member care quality or claim payments, and they remain committed to serving their community with integrity.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Medicare Fraud Settlement Hits Independent Health Settlement Overview Independent Health faces a massive $98 million settlement over Medicare Advantage fraud&#8230; <a href=\"https:\/\/distilinfo.com\/healthplan\/medicare-fraud-settlement-hits-independent-health\/\" style=\"white-space: nowrap;\">Continue Reading <i class=\"fas fa-long-arrow-alt-right\" style=\"vertical-align: middle;\"><\/i><\/a><\/p>\n","protected":false},"author":1,"featured_media":13867,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[1],"tags":[591,592,595,590,589,596,593,594],"class_list":{"0":"post-13862","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-distilinfo-originals","8":"tag-dxid-subsidiary","9":"tag-healthcare-fraud-settlement","10":"tag-healthcare-reimbursement-fraud","11":"tag-independent-health-settlement","12":"tag-medicare-advantage-fraud","13":"tag-medicare-risk-scores","14":"tag-medicare-upcoding","15":"tag-whistleblower-settlement","16":"entry"},"_links":{"self":[{"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/posts\/13862"}],"collection":[{"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/comments?post=13862"}],"version-history":[{"count":1,"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/posts\/13862\/revisions"}],"predecessor-version":[{"id":13865,"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/posts\/13862\/revisions\/13865"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/media\/13867"}],"wp:attachment":[{"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/media?parent=13862"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/categories?post=13862"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/tags?post=13862"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}