Company routinely added ‘bogus diagnosis coding,’ DOJ says
DOJ officials said that from 2020 to 2023, Complete Health routinely added “bogus diagnosis coding” to its billing, claiming patients had conditions that were not supported by their medical records. The diagnoses at issue included drug and alcohol dependencies and bipolar disorder.
Under Medicare Part C, also known as Medicare Advantage, the government pays private health providers a fixed monthly rate depending on the severity of a patient’s diagnosis. This differs from Medicare parts A and B, in which a provider is paid fees per service. The Justice Department alleged that Complete Health added the false diagnoses to receive a higher monthly premium per patient.
“Companies that attempt to improperly boost their own profits by reporting bogus medical conditions of Medicare Advantage enrollees — as alleged in this case — will be held responsible for their actions,” Isaac Bledsoe, special agent in charge at the Department of Health and Human Services Office of Inspector General, said in a statement.
“Today’s settlement demonstrates our office’s commitment to safeguarding the integrity of federal health care programs, including Medicare Advantage, which exist to provide necessary care to enrollees, not as a vehicle for improper financial gain,” Bledsoe added.
U.S. Attorney Gregory Kehoe of the Middle District of Florida said the settlement “sends a strong message to our district, its residents, and medical providers doing business here, that our focus on this vital practice area has not wavered.”
Complete Health is a management services organization based in Jacksonville that operates in Florida, Alabama and Colorado.