Martin’s Point Health Care Inc. (Martin’s Point), headquartered in Portland, Maine, has agreed to pay $22,485,000 to resolve allegations that it violated the False Claims Act by submitting inaccurate diagnosis codes for its Medicare Advantage Plan enrollees in order to increase reimbursements from Medicare.

Under Medicare Advantage, also known as the Medicare Part C program, Medicare beneficiaries have the option of enrolling in managed care insurance plans called Medicare Advantage Plans (MA Plans). MA Plans are paid a per-person amount to provide Medicare-covered benefits to beneficiaries who enroll in one of their plans. The Centers for Medicare and Medicaid Services (CMS), which oversees the Medicare program, adjusts the payments to MA Plans based on demographic information and the diagnoses of each plan beneficiary. The adjustments are commonly referred to as “risk scores.” In general, a beneficiary with diagnoses more expensive to treat will have a higher risk score, and CMS will make a larger risk-adjusted payment to the MA Plan for that beneficiary.

Martin’s Point operates Medicare Advantage plans for beneficiaries living in Maine and New Hampshire. The United States alleged that, from 2016 to 2019, Martin’s Point engaged in chart reviews of their Medicare Advantage beneficiaries to identify additional diagnosis codes that had not been submitted to Medicare. Many of the additional codes submitted, however, were not properly supported by the patients’ medical records. The government alleged that Martin’s Point nevertheless submitted those diagnosis codes, which resulted in higher payments from CMS.

The civil settlement includes the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by Alicia Wilbur, a former manager in Martin’s Point’s Risk Adjustment Operations group. Under those provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery. The qui tam case is captioned U.S. ex rel. Wilbur v. Martin’s Point Health Care Inc., No. 2:18-cv-00254 (DME). As part of today’s resolution, the whistleblower will receive approximately $3.8 million.   back...