Martin's Point Health Care will pay over $22M for alleged billing fraud
Alexis Wells
Martin's Point Health Care, whose primary care center at Portland, is shown here, will pay over $22 million to settle Medicare fraud allegations.
Portland-based Martin's Point Health Care has agreed to pay more than $22 million to the federal government to settle civil fraud allegations involving the health care provider's insurance claims under the Medicare Advantage program.
The fraud allegations were brought to light by a whistleblower, Alicia Wilbur, who was the Medicare risk adjustment operations manager at Martin's Point from mid-2016 through late 2017. She filed a lawsuit against the company in 2018.
According to the lawsuit, from 2016 to 2019 Martin's Point knowingly submitted diagnosis codes that were not supported by medical records, making patients appear sicker than they were. As a result, the provider obtained higher fees than it was entitled to receive from the Centers for Medicare & Medicaid Services.
The settlement is believed to be the largest ever in Maine under the Medicare Advantage program.
"False and unsupported medical diagnoses indicate patients have medical conditions that they don't really have and, in the Advantage context, cost the government millions of dollars," said Jeffrey W. Dickstein, attorney and partner at Phillips & Cohen LLP, representing Wilbur.
In the Medicare Advantage program, private health-insurance organizations, like Martin's Point, agree to provide Medicare coverage to beneficiaries in exchange for a fixed monthly payment from CMS. Payments vary on the patient and the health of each patient. Organizations receive more money for patients who are sicker because the cost of care is higher. The payment will be lower if the patient is relatively healthy.
“Medicare Advantage programs rely on accurate health information to provide the best healthcare and proper payment from the federal government,” said Amy L. Easton, another attorney and partner at Phillips & Cohen. “Inaccurate diagnosis codes distort both the delivery of healthcare and government payment for that healthcare.”
Martin's Point provides primary care to patients at six locations: Portland, Biddeford, Brunswick, Scarborough, Gorham and Portsmouth, New Hampshire. It also offers a Medicare Advantage plan that covers about 60,000 members.
Martin's Point could not be immediately be reached for comment.
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Why are there no criminal charges? The CEO and top leaders should be brought to court for knowingly bilking the Medicare program out of millions of dollars. If not for the whistleblower, I'm sure it would have continued to this day.
This practice of overbilling also seems to happen in the annual exams so when you talk to your Dr. and discuss what has been happening in the past year if they find any reason to either, change a prescription or maybe have to do a new blood work from a preventive point of view they now can charge you for an office visit even though this was done at your annual. This was what I thought was the reason for having an annual is to have a conversation with your Dr. at these which are covered by most insurance companies.
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