Medicare Advantage Fraud and False Claims Act Liability

Medicare Advantage fraud investigations often involve allegations that false diagnosis codes, unsupported risk-adjustment data, improper referral arrangements, or other inaccurate information caused the federal government to pay more than it should have under the Medicare Advantage program. Many of these investigations proceed under the Federal False Claims Act (FCA), but the government must still prove that the FCA’s requirements have been met.

If the feds are investigating you for Medicare Advantage fraud, connect with the Law Offices of Peter Katz to get the defense you deserve from our seasoned Medicare fraud defense attorney in New York.

What is Medicare Advantage Fraud?

Medicare Advantage, also called Medicare Part C, allows private insurers to administer Medicare benefits while receiving payments from the federal government. Those payments are adjusted in part on the documented health conditions of enrolled beneficiaries, a process known as risk adjustment.

Fraud allegations may arise when investigators believe inaccurate information affected those payments. Examples include:

• False, inaccurate, or incomplete medical records
• Billing for medically unnecessary services
• Improper risk-adjustment submissions
• Kickback or referral arrangements
• Unsupported diagnoses identified only through chart reviews or health risk assessments
• Failure to delete invalid diagnosis codes used for risk adjustment

For example, investigators may question whether the medical record adequately supported a diagnosis that increased a patient’s risk-adjusted payment. They may examine whether the documentation accurately reflected the patient’s condition and whether the diagnosis was properly submitted in accordance with Medicare Advantage requirements.

Why is The DOJ Investigating Medicare Advantage Fraud?

Recent HHS-OIG reports found that unsupported diagnoses reported through health risk assessments and chart reviews can increase Medicare Advantage payments by billions of dollars. As a result, federal investigators continue to focus on whether the underlying medical records support submitted diagnoses.

How Does The False Claims Act Apply in New York Medicare Advantage Fraud Cases?

According to 31 U.S.C. § 3729, the federal False Claims Act allows the government to pursue civil liability against anyone who knowingly submits, or causes another individual to submit, false or fraudulent claims for payment to the government. In Medicare Advantage investigations, the government may argue that unsupported diagnosis codes or inaccurate risk-adjustment information led the Centers for Medicare & Medicaid Services (CMS) to make higher payments than it otherwise would have.

For instance, investigators may allege that diagnoses submitted to increase a patient’s risk score were not supported by physician documentation or other medical evidence. Whether those allegations establish liability depends on the complete medical record, the provider’s documentation, and the available evidence, not simply the existence of higher reimbursement.

What Conduct May Create Liability Under The False Claims Act?

Every investigation depends on its facts, but common allegations include:

• Submitting unsupported diagnosis codes
• Failing to maintain documentation supporting reported conditions
• Billing for medically unnecessary services
• Falsifying patient records
• Causing inaccurate risk-adjustment submissions
• Participating in improper referral or compensation arrangements

What Should You Do If You Are Being Investigated for Medicare Advantage Fraud in New York?

Receiving an audit request, subpoena, Civil Investigative Demand (CID), or interview request doesn’t automatically mean you violated the law or that you’ll face civil or criminal liability. You must, however, take the situation seriously and consider taking the following steps:

• Preserve relevant records and electronic data.
• Avoid altering or destroying documentation.
• Review the government’s requests carefully.
• Notify appropriate internal leadership.
• Obtain legal guidance before responding to investigators.

Our Medicare fraud defense lawyer in New York can assess the government’s allegations, analyze supporting records, review your compliance efforts, respond to subpoenas and demands, and develop a defense strategy tailored to your specific circumstances.

Connect With Our Medicare Fraud Defense Lawyer Today

Medicare Advantage investigations often require a detailed review of diagnosis coding, medical documentation, risk-adjustment practices, compliance procedures, and communications with federal investigators. If you’re under investigation for Medicare Advantage fraud in New York, request your confidential consultation by contacting Peter Katz online or at 609-849-3179.