Two health plan vendors providing in-home and mobile health services, along with the founder of one of the firms, have agreed to pay a combined $56.5 million to resolve federal allegations that they submitted false diagnosis codes to inflate Medicare Advantage payments.
Matrix Medical Network, which contracts with health plans to conduct in-home health assessments, will pay $36.5 million. HealthFair, a mobile health services company Matrix acquired in 2018 and shut down by 2020, will pay $5 million. HealthFair founder Shahriah “James” Ekbatani will pay $15 million individually, the Justice Department said June 3.
The government alleges that between 2014 and 2019, Matrix caused MA plans to submit invalid diagnoses, including atrial fibrillation, rheumatoid arthritis, and chronic obstructive pulmonary disease, to CMS without sufficient clinical documentation to support them. For HealthFair, the alleged conduct spans 2015 to 2017 and includes diagnoses of HIV/AIDS, metastatic cancer, and congestive heart failure made without supporting medical records, or contradicted by test results.
The cases originated from whistleblower suits filed under the False Claims Act. A former Matrix employee will receive $7.3 million, and HealthFair’s former chief medical officer will receive $3.6 million.
“Our independence from insurers and flat-fee business model mean our sole incentive is providing exceptional in-home health assessment and care services that identify unmet needs and improve health outcomes for patients, all in compliance with the laws and regulations governing our industry,” a spokesperson for Matrix Medical Network told Becker’s. “These settlements relate to historical documentation practices regarding a discrete set of clinical diagnoses for Medicare Advantage patients that occurred under prior leadership between 2014 and 2019 and alleged conduct at a now-shuttered subsidiary that predated our 2018 acquisition. Since then, we have made meaningful investments in our compliance program and clinical documentation processes to ensure we meet or exceed all CMS and HHS-OIG standards and guidance. We are pleased to move beyond these matters and direct our full attention to providing high-quality patient care.”
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