WASHINGTON — Martin's Point Health Care Inc. agreed Monday to pay $22,485,000 in order to resolve allegations that it violated the False Claims Act between 2016 and 2019.
The U.S. Department of Justice said in a news release Monday that the organization allegedly violated the act by "submitting inaccurate diagnosis codes for its Medicare Advantage Plan enrollees in order to increase reimbursements from Medicare."
Martin's Point operates Medicare Advantage Plans, or MA Plans, for beneficiaries who are living in Maine and New Hampshire, the DOJ said.
"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," the release stated. "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 [the Centers for Medicare and Medicaid Services."
The civil settlement reportedly includes the resolution of claims brought under the whistleblower provisions of the False Claims Act by Alicia Wilbur, who is a former manager in Martin's Point's Risk Adjustment Operations group, according to the release. The whistleblower will receive around $3.8 million as part of Monday's solution.
"The government expects those who participate in Medicare Advantage to provide accurate information to ensure that proper payments are made for the care received by enrolled beneficiaries," Deputy Assistant Attorney General Michael D. Granston of the Justice Department's Civil Division, Commercial Litigation Branch said in the release. "Today’s result sends a clear message to the Medicare Advantage community that the United States will take appropriate action against those who knowingly submit inflated claims for reimbursement."
A spokesperson for Martin's Point said the following in a statement Monday:
"This settlement is not an admission of liability, it instead allows us to avoid the disruption, expense, and uncertainty of litigation. It is important to note that this investigation is unrelated to member care or payment of member claims. This resolution allows us to put the past behind us, and we remain committed to our patients and members across our service regions and to the regulatory agencies that oversee our work."
This matter was handled by Trial Attorney J. Jennifer Koh of the Justice Department’s Civil Division, as well as Assistant U.S. Attorneys John Osborn and James Concannon for the District of Maine with the assistance of the U.S. Attorney’s Office’s in-house auditor, the release said.
"The claims resolved by the settlement are allegations only and there has been no determination of liability," the DOJ said Monday.