News Briefs

The U.S. Dept. of Justice has intervened in six False Claims Act complaints accusing Kaiser Permanente of submitting inaccurate diagnosis codes to receive inflated Medicare Advantage reimbursements. According to a July 30 press release, the DOJ intervened in cases filed against the following Kaiser Permanente consortium members: Kaiser Foundation Health Plan Inc., Kaiser Foundation Health Plan of Colorado, The Permanente Medical Group Inc., Southern California Permanente Medical Group Inc. and Colorado Permanente Medical Group P.C. The suits alleged that “Kaiser allegedly pressured its physicians to create addenda to medical records after the patient encounter, often months or over a year later, to add risk-adjusting diagnoses that patients did not actually have and/or were not actually considered or addressed during the encounter, in violation of Medicare requirements,” said DOJ. In a statement on its website, Kaiser Permanente said it intends to “strongly defend against the lawsuits” and is confident in its compliance with Medicare program requirements. “Our policies and practices represent well-reasoned and good-faith interpretations of sometimes vague and incomplete guidance from CMS. For nearly a decade, Kaiser Permanente has achieved consistently strong performance on Risk Adjustment Data Validation audits conducted by CMS. With such a strong track record with CMS, we are disappointed the Department of Justice would pursue this path,” stated the not-for-profit insurer.

Anthem, Inc. and Kroger Health have teamed up to offer a Medicare Advantage plan in 2022, according to HealthPayerIntelligence. The new co-sponsored plan will be offered in the Atlanta, Cincinnati, Louisville, Ky., and southern Virginia regions. Meanwhile, Highmark Blue Cross Blue Shield Delaware said it is partnering with two Delaware-based health systems, ChristianaCare and Bayhealth, to offer an MA product next year. According to AIS’s Directory of Health Plans, just 93 of Highmark’s 235,382 MA members reside in Delaware, so the new offering stands to grow the insurer’s presence significantly.

© 2024 MMIT
Lauren Flynn Kelly

Lauren Flynn Kelly Managing Editor, Radar on Medicare Advantage

Lauren has been covering health business issues since the early 2000s and specializes in in-depth reporting on Medicare Advantage, managed Medicaid and Medicare Part D. She also possesses a deep understanding of the complex world of pharmacy benefit management, having written AIS Health’s Radar on Drug Benefits from 2004 to 2005 and again from 2011 to 2016. In addition to her role as managing editor of Radar on Medicare Advantage, she oversees AIS Health’s publications and manages the health editorial staff. She graduated from Vassar College with a B.A. in English.

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