The lawsuit remained under federal court seal until Feb. 26, according to a comprehensive NPR report. Here are four major takeaways from the NPR piece.
1. The suit targets Humana’s risk-adjustment practices. CMS pays Medicare Advantage insurers like Humana partially based on risk scores, which indicate how sick members are. Inflated risk scores have cost taxpayers billions of dollars in recent years.
2. Whistle-blower accusations involving fraudulent risk scores are not new. This particular suit treads some new ground in that Dr. Baez alleges inflating risk scores not only wastes taxpayer money, but can also incite patient harm and inadequate care. According to NPR, in a letter to the presiding judge, Dr. Baez wrote that treating elderly patients with “multiple ailments” is difficult when you have accurate data, but “when medical records are poisoned with misleading data [from inflated risk scores] it becomes Russian roulette.”
3. Dr. Baez and Dr. Thompson were partners in two clinics in Humana’s network, Lake Worth (Fla.) Medical and IM Medical in Boynton Beach Fla., from 2003 to 2012. Dr. Baez alleges that in February 2009 he developed suspicions in regards to clinic billing practices. He allegedly spoke to physicians that worked there about said practices. They stated that Dr. Thompson had instructed them to “upcode” diagnoses. Dr. Baez alleges he reported the abuses to Humana in May 2009, but the company failed to take appropriate action. In 2012, Dr. Baez contacted the FBI. Dr. Thompson was indicted on healthcare fraud charges last year. The suit also names three other physicians, two medical clinics and a physician’s practice group as defendants.
4. In the suit, Dr. Baez alleges that Humana encouraged overbilling by giving network physicians forms highlighting “more profitable” diagnosis codes they could utilize for patients. Humana, citing company policy to not comment on pending litigation, did not offer comment to NPR.
5. In 2015, the Department of Justice issued an information request to Humana related to its Medicare Advantage risk-adjustment practices. The request was “separate but related to” a whistle-blower lawsuit filed under the False Claims Act by Olivia Graves, MD.
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