In the latest False Claims Act settlement involving allegations of Medicare Advantage “upcoding,” Sutter Health and its affiliates agreed to pay $90 million to resolve claims that they knowingly submitted inaccurate information about the health status of beneficiaries enrolled in MA plans. Those claims were initially raised in a whistleblower lawsuit (U.S. ex rel. Ormsby v. Sutter Health, et al., No. 15-CV-01062-LB), filed by a former employee of Palo Alto Medical Foundation, an entity affiliated with Sutter Health. According to the Dept. of Justice’s complaint-in-intervention, the federal government alleged that the health system submitted unsupported diagnosis codes for certain patient encounters, causing inflated payments to be made to the MA plans covering those beneficiaries and to Sutter Health. The lawsuit also alleged that, once the provider organization became aware of these unsupported diagnosis codes, it “failed to take sufficient corrective action to identify and delete additional unsupported diagnosis codes.”

The House on Aug. 24 approved President Joe Biden’s multimillion-dollar fiscal blueprint, paving the way for legislators to draft the Build Back America plan this fall. The Senate in August passed the $3.5 trillion resolution framework, which included expanding Medicare benefits, lowering the Medicare eligibility age, and enhancing funding for Medicaid Home and Community-Based Services. The resolution provided a target date of Sept. 15 for the Senate committees to submit their reconciliation legislation. Meanwhile, Wakely estimated that the addition of hearing, dental and vision benefits in Medicare would result in a per-beneficiary reduction of about $696 to $1,056 a year in added benefits if Medicare Advantage rates aren’t adjusted. If Congress adds these benefits to Original Medicare without adjusting the MA benchmark, plans would have an average of 48% to 73% fewer rebate dollars to fund supplemental benefits such as transportation, meals, in-home services and supports, and over-the-counter medicines, according to the report prepared for AHIP.

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