UPDATE: August 2, 2021: Kaiser Permanente disputes the allegations and said it is disappointed that the DOJ is taking this path. In a statement, the system said: “We are confident that Kaiser Permanente meets the requirements of the Medicare Advantage program and we intend to vigorously defend ourselves against lawsuits alleging otherwise.”
- The Justice Department is intervening in six trials alleging that Kaiser Permanente submitted inaccurate diagnostic codes to receive higher reimbursement from the Medicare Advantage program.
- The lawsuits allege that Kaiser pressured doctors to add diagnoses to patients ‘medical records – diagnoses they didn’t actually have – to increase patients’ risk scores and get higher payments. These records were allegedly altered months or even a year later, the DOJ said.
- All six lawsuits were filed by whistleblowers, in one case a Kaiser data clerk, and they contend that Kaiser violated the False Claims Act.
The government spends billions of dollars on the Medicare Advantage program each year as more seniors turn to the program instead of traditional Medicare coverage.
But a seemingly perennial problem with the show is plans that try to manipulate the system to secure higher payouts.
MA plans are paid per member. Those payments are then adjusted to reflect the acuteness or severity of the patient’s health condition. Generally, the sicker a member is, the higher the reimbursement.
A recent report found that $ 2.6 billion was spent on diagnostic codes that were not justified. It’s a problem that federal regulators are concerned about, and they are trying to keep a close eye on.
“Today’s action sends a clear message that we will hold health care providers and plans accountable if they seek to mislead the system by submitting false information,” the DOJ said in a statement.
Kaiser Permanente operates one of the largest MA plans by membership, according to the Kaiser Family Foundation. Overall, Kaiser has a 7% market share in the MA program, behind giants like UnitedHealthcare, Humana, Blue Cross Blue Shield plans, and CVS Health.
Kaiser Permanente did not immediately respond to a request for comment.