A Jacksonville-based healthcare company is set to pay $14.1 million to resolve federal allegations that unsupported mental-health and substance-use diagnoses were used to inflate Medicare Advantage payments. The case puts a local senior-care provider at the center of a growing national fight over how medical coding drives taxpayer-funded insurance dollars.
News4JAX reported that Complete Health Partners Holdings agreed to the settlement after prosecutors alleged the company caused false diagnosis codes to be submitted between 2020 and 2023. The company manages affiliated provider groups in Florida, Alabama and Colorado, according to the report.
How Diagnosis Codes Can Change Medicare Payments
Medicare Advantage plans receive fixed monthly payments for enrollees, but those payments are adjusted using reported diagnoses and risk scores. The HHS inspector general has warned that unsupported diagnoses can produce improper risk-adjusted payments because sicker patients generally generate higher reimbursement.
In Complete Health’s case, the government alleged that coders and doctors were pushed to add codes for drug and alcohol dependence, as well as major depressive, bipolar and paranoid disorders. Prosecutors said many of the codes were not clinically valid, were unsupported by medical records or were unrelated to the patients’ care, as detailed by News4JAX…