A settlement has been reached to resolve False Claims Act allegations against Sutter Health LLC and an affiliated entity, Palo Alto Medical Foundation.
The allegations arose from a lawsuit that claimed Sutter Health LLC and Palo Alto Medical Foundation submitted inaccurate information about the health status of beneficiaries enrolled in Medicare Advantage Plans.
According to the government, allegedly Sutter and the Palo Alto Medical submitted inaccurate codes that inflated the risk scores of patients on the Medicare Advantage program, and enabled Sutter to reap greater reimbursements from the Centers for Medicare and Medicaid Services, which oversees the Medicare program. In addition, allegedly when the Palo Alto Medical Foundation became aware of these inaccurate diagnosis codes, it failed to identify and delete additional potentially inaccurate codes that would result in a higher payment to Sutter.
“This intervention illustrates our commitment to protecting the integrity of the Medicare Advantage program,” said U.S. Attorney Alex G. Tse for the Northern District of California. “The share of Medicare beneficiaries enrolled in Medicare Advantage has steadily grown over the past decade, with 19 million beneficiaries enrolled in 2017. It is critically important that the data submitted to the Medicare Advantage program is truthful, because the government relies on this information to set payment levels. We will continue to guard government health programs from companies that improperly maximize their bottom line at taxpayer expense.”
The Whistleblower, Kathleen Ormsby, a former employee of Palo Alto Medical Foundation, will receive a share of any recovery.
