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Complete Health to pay $14M to settle Medicare Advantage fraud allegations
['Rebecca Pifer Parduhn', 'Emily Olsen', 'Senior Reporter']
Healthcare Dive - Latest News
Dive Brief:Complete Health, a value-based primary care provider in three states, has agreed to pay $14.1 million to settle accusations that it overcharged Medicare, the latest instance of a company dinged for allegedly gaming Medicare Advantage in order to profit.
Dive Insight:In MA, the government pays insurers a fixed payment per member each month that’s adjusted higher or lower based on the health needs of their enrollees.
That creates an incentive for MA organizations to exaggerate their members’ health needs to inflate their revenue, a practice called upcoding.
Though major MA insurers are most frequently criticized for upcoding, smaller entities haven’t been immune.
The CMS has moved ahead with accelerated audits of MA plans and clawed back overpayments, including from major for-profit insurers.