The Department of Justice announced a more than half-billion-dollar settlement with Kaiser Permanente over claims the health care provider submitted false diagnosis codes for Medicare Advantage Plan customers in order to receive a higher payout from the government.
In a 2022 complaint, the Department of Justice claimed Kaiser violated the False Claims Act from 2009 to 2018 in order to “unlawfully obtain payments,” from the Medicare Part C program.
Prosecutors alleged that Kaiser made “efforts to increase its Medicare revenue by systematically pressuring its physicians to add diagnoses that did not appear in the original visit note.”
Kaiser responded Thursday with a statement that confirmed the settlement, denied any liability and wrongdoing and said the allegations never interfered with patient care. The settling affiliates for the national consortium based in Oakland included Southern California Permanente Medical Group, the Kaiser Foundation Health Plan Inc. and The Permanente Medical Group.
The federal claims indicate that doctors were pressured to add diagnostic codes and the government was the primary victim, for “additional Medicare payments in the range of $1 billion from these diagnoses.”
In some cases, according to the federal complaint, “Kaiser mined Medicare Advantage patient medical files for potential additional diagnoses … pressed its physicians to add the diagnoses to medical records retrospectively using an addendum to make it appear as if the conditions had been addressed in some way during the patient visit when in fact they had not … In many cases, patients were not even told that they supposedly had the diagnoses that Kaiser had added to their medical records,” according to a “preliminary statement.”
A statement Thursday from Kaiser sent via email stated the organization chose to settle for the sake of expediency, and a prevalence of similar cases point to “industrywide challenges in applying these requirements,” referring to what it called the government’s “scrutiny over Medicare Advantage risk adjustment standards and practices.”
Kaiser officials said there was no admission of wrongdoing or liability.
“The Kaiser Permanente case was not about the quality of care our members received. It involved a dispute about how to interpret the Medicare risk adjustment program’s documentation requirements,” according to a statement shared Thursday by Carol Soudah through Kaiser’s Office of Public Affairs. “We remain unwavering in our mission to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve.”