A Texas whistle-blower lawsuit alleges Dallas-based ConseoHealth, a medical consulting firm, and 30 Medicare Advantage plans inflated charges for home visits by exaggerating patients' risk scores, according to the Center for Public Integrity.
Here are nine things to know about the case, which was unsealed in mid-June.
1. The lawsuit alleges the defendants' health assessments exaggerated patients' risk scores, which are used to set monthly Medicare Advantage reimbursements. It alleges physicians took vital signs and weights, but did not deliver a physical exam or lab tests. The lawsuit claims physicians merely asked patients a set list of questions, basing diagnoses on medications or self-reported conditions. "In other words, the conditions reflected on the evaluation forms are not medical diagnoses derived from a medical examination, but instead, are self-reported conditions captured from the medical history and verbally confirmed" by the patient, the lawsuit reads.
2. The lawsuit also alleges some of the physicians lacked medical licenses and some submitted false test results, according to the report.
3. Thirty Medicare Advantage plans across 15 states were named, including multiple Blue Cross plans and Humana plans, according to the report.
4. Though recently unsealed, Becky Ramsey-Ledesma, a former ConseoHealth employee, filed the lawsuit under the qui tam, or whistle-blower, provisions of the False Claims Act a year ago. According to the report, Ms. Ramsey-Ledesma claims she was let go the day after she showed opposition to the company's practices.
5. ConseoHealth did not comment on the lawsuit, according to the report.
6. This is the second whistle-blower case involving Medicare Advantage home visits, and one of about half a dozen actions filed in the past five years alleging Medicare Advantage fraud. The other case targeting home visits was unsealed last year and filed against Santa Ana, Calif.-based Mobile Medical Examination Services, who denied the allegations, according to the report.
7. The Department of Justice has declined to join both the ConseoHealth case and the Mobile Medical Examination Services case, according to the report. Therefore, the whistle-blowers in each of the cases will prosecute the claims.
8. A 2014 Center for Public Integrity investigation revealed home visits had shot up and found federal officials backed off a proposal to limit home visits when the healthcare industry objected. Officials had indicated home visits may have been a factor in improperly high risk scores and Medicare overcharges, according to the report.
9. When asked to comment on its home visit policy, CMS gave the following statement, according to the report: "CMS believes that in-home assessments can have significant value as care planning and care coordination tools. In the home setting, the provider has access to more information than is available in a clinical setting."
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