Whistleblower Cases Target Medicare Advantage Home Health Visits

A series of whistleblower cases over how Medicare Advantage plans utilize in-home health assessments to set their payment rates has raised concerns over poor government oversight.

Filed in 2014 and unsealed by the federal court in Dallas in June, the case against CenseoHealth LLC is one of several such suits filed in the past five years, and only the second whistleblower case to target Medicare Advantage in-home assessments, the Center for Public Integrity reported this week.

As an alternative to standard Medicare, which pays physicians for services administered, Medicare Advantage plans receive a set monthly payment for each patient based on a risk score, getting higher rates for the sickly and less for those in good health, the CPI article stated. The number of beneficiaries has ballooned to 17 million people, according to the CPI.

The most recent lawsuit was filed by a former employee of the Dallas-based firm CenseoHealth LLC, a company that conducts home visits to provide patients’ health information to health plans for use to bill Medicare. The suit alleges the company contracted with thousands of doctors to evaluate elderly patients’ health on behalf of Medicare Advantage plans, and then some of these doctors exaggerated or altered their patient assessments to inflate their risk scores so that the plan could receive more money from Medicare.

Meanwhile, federal officials grapple with preventing health plans from overcharging Medicare by tens of billions of dollars every year as home visits escalate, according to a 2014 Center for Public Integrity investigation. And in 2013, when federal officials stepped forward to voice their concerns about home visits inaccurately raising risk scores and wasting tax dollars, they received backlash from the industry and therefore backed off a proposal to limit the home health visits, according to the investigation. In fact, a bill passed by the House in June seems to block government officials from stopping these types of home health evaluations.

CenseoHealth had no comment on the latest lawsuit, according to the CPI report, and the Centers for Medicare & Medicaid Services issued a prepared statement touting the value of home exams.

Written by Kourtney Liepelt