Portland, Maine-based Martin's Point Health Care has agreed to pay $22.5 million to resolve allegations that it knowingly submitted inaccurate diagnosis codes for Medicare Advantage Plan enrollees to increase reimbursements from Medicare.
Four things to know:
1. Prosecutors allege that Martin's Point — which operates Medicare Advantage plans for beneficiaries in Maine and New Hampshire — reviewed charts of their Medicare Advantage beneficiaries to identify additional diagnosis codes that had not been submitted to Medicare.
2. Many of the additional codes allegedly submitted were not properly supported by patients' medical records, but Martin's Point still submitted those codes, which resulted in higher payments from CMS, according to the Justice Department.
3. The settlement resolves claims brought under the qui tam or whistleblower provisions of the False Claims Act by Alicia Wilbur, a former manager in Martin's Point risk adjustment operations group. She will receive about $3.8 million. The settlement is not an admission of any wrongdoing by Martin's Point.
4. With about a 33 percent market share, Martin's Point is the largest Medicare Advantage payer in Maine, according to a study published Nov. 1 by the American Medical Association.