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Whistleblower lawsuit in Texas alleges fraud by Medicare Advantage plans through home visit health assessments

News reports are once again highlighting fraud by MedicareAdvantage plans to boost their revenues. The most recent whistleblower case that has been made public involves home health visits.

The “qui tam”(whistleblower) lawsuit alleges that CesneoHealth, which provides home visit health assessments, had been exaggerating the severity of their elderly patients’ illnesses to increase Medicare payments to the plans.

The lawsuit, filed in Texas, targets CesneoHealth and 30 Medicare Advantage plans in fifteen states, including multiple Blue Cross and Humana Inc. plans. These private insurance plans receive monthly per-patient payments from Medicare based on the estimated risk factor of the patients.

The case alleges that home visits to elderly patients resulted in diagnoses based on little more than self-reported conditions and brief evaluations. Many of the doctors reportedly were practicing without a license or making up to ten visits a day for a flat rate of $100 per visit. According to the whistleblower lawsuit, those visits increased risk scores improperly, leading to substantial overpayments to the health plans.

There are now at least a half dozen whistleblower cases that have been made public alleging billing fraud by Medicare Advantage plans, according to the Center for Public Integrity, an investigative journalism nonprofit.

A 2014 Center for Public Integrity investigation found that billions of tax dollars were being spent annually on fraudulent claims of high risk factors for elderly at-home patients to manipulate Medicare payments.

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