Whistleblower Doctor to Reap Nearly $850K for Medicare Advantage Provider’s Alleged Inflated Claims
Photo: Dr. Sherif Khalil
REDLANDS – A Medicare Advantage Provider, Beaver Medical Group L.P, along with one of its doctors have reached a settlement agreement. They’ll pay $5,039,180 for allegedly reporting invalid diagnoses to Medicare Advantage Plans.
Allegations were brought in a whistleblower lawsuit, filed under the qui tam provisions of the False Claims Act. Dr. David Nutter, a former employee of Beaver, will receive approximately $850,000.
Dr. Nutter sued on behalf of the government for false claims of government funds. He will receive a share of any recovery, because the whistle-blower act permits private parties to sue.
“Beaver and one of its physicians, Dr. Sherif Khalil, will resolve allegations that they reported invalid diagnoses to Medicare Advantage plans and thereby caused those plans to receive inflated payments from Medicare,” said the Justice Dept. on August 8th. Beaver is headquartered in Redlands, California.
“The United States relies on healthcare providers to submit accurate diagnosis data to Medicare Advantage plans to ensure those plans receive the appropriate compensation from Medicare,” said Assistant Attorney General Jody Hunt of the Dept. of Justice’s Civil Division. “We will pursue those who undermine the integrity of the Medicare program and the data it relies upon.”
The Medicare Part C program of Medicare Advantage gives Medicare beneficiaries the option to obtain health care coverage through private insurance plans that are owned and operated by private insurers known as Medicare Advantage Organizations (MAOs).
“Medicare pays MAOs a fixed, monthly amount to provide health care coverage to Medicare beneficiaries who enroll in their plans. Medicare adjusts these monthly payments to reflect the health status of each beneficiary, explained DOJ. “In general, Medicare pays MAOs more for sicker beneficiaries and less for healthier ones.”
Several of the MAOs had contracted with Beaver to provide care to Medicare beneficiaries. Beaver was often compensated with a share of the payments for Beaver’s beneficiaries. The settlement resolves allegations that Beaver and Dr. Khalil submitted diagnoses not supported by medical records, which inflated payments for risk-adjusted care to patients.
The Civil Division’s Commercial Litigation Branch and the Dept. of Health and Human Services, Office of Inspector General handled the matter. The claims resolved by the settlement are allegations only. There has been no determination of liability.
Timothy B. Francesca, Acting Special Agent in Charge for the Office of Inspector General of the U.S. Department of Health and Human Services said, “Those who inflate bills sent to government health programs can expect to pay a heavy price.”
Government intervention illustrates emphasis on combating health care fraud. The False Claims Act is one of the most powerful fraud-prevention tools. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement can be reported to the Department of Health and Human Services, at 800-HHS-TIPS (800-447-8477).