Risk Adjustment Fraud?

making patients look sicker than they are,”

False COVID Statistics?

With COVID going on, so many on Facebook are saying the COVID numbers are inflated so that hospitals & insurance companies can get more $$$.   Based on the rules of Risk Adjustment Fraud, I don’t think so.  Here’s the CDC rules for reporting deaths due to COVID.   See also the video at right or scroll down.


UHC and Anthem Blue Cross (and another article) were once accused of “gaming” the Medicare Advantage payment system by

making patients look sicker than they are,”  Risk Adjustment Fraud?

Damages are speculated to top $1 billion.

Medicare Advantage is a popular alternative to traditional Medicare. The privately run health plans have enrolled more than 18 million elderly and people with disabilities — about a third of those eligible for Medicare — at a cost to taxpayers of more than $150 billion a year.

“This is not one company engaged in episodic bad behavior, but a lucrative business plan that appears to be national in scope,”

When Congress created the current Medicare Advantage program in 2003, it expected to pay higher rates for sicker patients than for people in good health using a formula called a risk score.

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Court Rules in favor of UHC

CA Health Line 5.17.2017  79 page lawsuit filed

CA Health Line 3.28.2017

public integrity.org/medicare-advantage-money-grab

Medicare Managed Care Manual
Chapter 7 – Risk Adjustment 


sheppard health law.com/doj/unitedhealth-group/

1st amended complaint?

CMS identified violations and sent a notice on 11.22.2016 of Part D formulary and benefit administration requirements that resulted in UnitedHealth ’s enrollees experiencing inappropriate denials of and/or delayed access  to Part D prescription drugs at the point of sale.  The fine is $2.5M.

CA Healthline 5.30.2017 Freedom Health & Optimum Health Care settle for a $32m fine

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