On July 31, the Department of Justice (DOJ) announced Martin’s Point Health Care Inc. (Martin’s Point), has agreed to pay $22,485,000 to resolve allegations, without admitting or denying the validity of the claims, that it violated the False Claims Act (FCA). According to its website, Martin’s Point is a health care provider with six locations between Maine and New Hampshire with over 1,000 employees and over 90,000 patients.
Alicia Wilbur, a former manager in Martin’s Point’s Risk Adjustment Operations group, blew the whistle on the fraud by filing a civil suit under the qui tam provision of the FCA. Qui tam claims enable private citizens to file lawsuits on behalf of the government if they know of an individual or company defrauding the government. Qui tam whistleblowers are eligible to receive between 15 and 30% of the government’s recovery. Ms. Wilbur will receive approximately $3.8 million as her share of the federal recovery.
The government alleged Martin’s Point, which operates Medicare Advantage plans, performed a chart review of submitted Medicare claims to see if any were missing. The government claimed that many new codes were submitted, but they were not supported by the patients’ charts, which in turn led to higher, fraudulent payments to Martin’s Point.
In the press release, the DOJ notes several quotes, including ones such as “[t]he 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,” said Deputy Assistant Attorney General Michael D. Granston of the Justice Department’s Civil Division, Commercial Litigation Branch. “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.”
The DOJ additionally notes agency positions, “[i]t is a privilege for health plans to provide services to Medicare beneficiaries, not a right. Medicare Advantage Plan sponsors that submit inaccurate claim information in order to justify inflated payments undermine the financial integrity of the program,” said Deputy Inspector General for Investigations Christian J. Schrank at the Department of Health and Human Services, Office of Inspector (HHS-OIG). “HHS-OIG remains committed to protecting taxpayer-funded health care programs, including Medicare Advantage.”
Over the past term, the United States Supreme Court has upheld anti-fraud protections. On June 1, the U.S. Supreme Court issued a unanimous decision in United States ex rel. Schutte v. SuperValu Inc. The decision, heralded as a major victory by whistleblower advocates, overturns U.S. Court of Appeals rulings which allowed fraudulent companies to escape liability under the False Claims Act if they could prove their fraudulent actions could be based on a “reasonable interpretation of the law” regardless of whether or not the company intended to commit fraud.
On July 25, a bipartisan group of senators introduced the False Claims Amendments Act of 2023, which address a few technical loopholes undermining the success of the FCA.