Fraud invading Medicare Advantage Plans seniors beware

Federal prosecutors in Florida are pursuing an unusual criminal fraud case taking aim at billing practices of Medicare Advantage plans, which are popular with seniors because out-of-pocket costs are lower and they provide more benefits than traditional Medicare. The case centers on a South Florida doctor affiliated with Humana Inc., one of the industry’s biggest players.

A federal grand jury in West Palm Beach, Fla., indicted the doctor, Isaac Kojo Anakwah Thompson, on eight counts of health care fraud on Feb. 4. He’s accused of cheating Medicare out of about $2.1 million by claiming his Humana-enrolled patients were sicker than they actually were. Thompson, 55, was arrested and is free on a $1 million bond. Through his lawyer, he declined to comment.

The indictment does not accuse Humana of wrongdoing and the company has repaid the Government.

However, the case is highlighting potential billing fraud and abuse in Medicare Advantage as well as questions about the effectiveness of government oversight of the fast-growing industry, which costs taxpayers more than $150 billion a year.

Medicare Advantage plans are paid a set fee monthly for each patient based on a complex formula known as a risk score. Essentially, the government pays higher rates for sicker patients and less for those in good health.

But overcharges, intentional or not, have cost taxpayers billions of dollars in recent years, as the Center for Public Integrity reported in a series published last year.

CMS officials concede that billions of tax dollars are misspent every year when Medicare Advantage plans exaggerate how sick their patients are, a practice known as “upcoding.” The Government Accountability Office, the watchdog arm of Congress, also is auditing Medicare Advantage billing practices. Results are due later this year.

Jeffrey Newman represents whistleblowers