A former employee of Cambia Health Solutions has accused the Portland, Ore.-based company of violating the False Claims Act by knowingly submitting inaccurate diagnosis data to CMS and failing to return Medicare Advantage overpayments.
The whistleblower complaint, originally filed in 2020, was unsealed July 20 in a Washington state federal court. During that period, the Justice Department investigated the claims and ultimately declined to pursue the matter further.
Cambia, which operates Regence-branded Blue Cross Blue Shield plans in Washington, Oregon, Utah and Idaho, covers roughly 125,000 Medicare enrollees.
The complaint alleges that Cambia submitted only a fraction of the “orphan claim deletes” its chart review identified for 2018, reporting about $4 million in deletions when the accurate figure was closer to $21 million, and that the company’s executives chose not to disclose the roughly $17 million discrepancy to CMS. The lawsuit also alleges Cambia altered vendor-supplied confidence scores to prompt providers to confirm unlikely diagnoses, and that it declined to expand internal audits because doing so would reduce revenue.
The complaint alleges Cambia’s own hired consultants flagged problems as early as 2011, when a mock audit found a 70% error rate in the plan’s submitted diagnosis codes. Cambia allegedly designed its chart reviews to catch only revenue-adding codes while ignoring ones that would require repayment, which the filing describes as searching for “only favorable reporting errors.”
“We believe the suit is without merit. We believe in our processes and are extremely pleased that the Department of Justice decided not to join the suit after it completed its review,” a Cambia spokesperson told Becker’s.
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