DaVita Medical Holdings will pay $270 million to resolve False Claims Act violation allegations related to inaccurate billing information that led to inflated payments from Medicare Advantage Plan beneficiaries.
Here are five things to know:
1. DaVita operated a Medicare Service Organization that contracted with Medicare Advantage Organizations in California, Nevada and Florida, as well as other states nationwide. DaVita collected and submitted diagnoses to the MAOs and received a share of the payments from CMS for their beneficiaries.
2. As part of a voluntary disclosure to the government, DaVita revealed that an independent physician association it acquired in 2012 submitted inaccurate diagnosis codes to CMS and received inflated payments as a result. The IPA, HealthCare Partners, shared in the payments along with DaVita.
3. HealthCare Partners circulated improper medical coding guidance, according to the Department of Justice report, that led to physicians using improper diagnosis codes for procedures. In one example, physicians used an improper code for spinal condition treatment that increased CMS reimbursement.
Due to self-disclosures and DaVita's cooperation with the government investigation, the U.S. agreed to a "favorable resolution of potential claims arising from this conduct."
4. DaVita agreed to pay $270 million which settles whistleblower allegations, alleging HealthCare Partners was involved in "one-way" chart reviews, searching medical records for diagnoses that providers may have "missed" and then submitting them to MAOs for increased Medicare payments. The allegations also accuse the IPA of leaving inaccurate diagnosis codes in submitted claims that should have been deleted.
5. The whistleblower for the "one-way" chart review allegations, who was a former MAO employee that did business with DaVita, received about $10.2 million of the settlement.