A major California-based medical provider has agreed to pay a total of $90 million to settle allegations of Medicare fraud, officials said Monday.
Sacramento-based Sutter Health, northern California's largest hospital system, got inflated payments because it said people in its Medicare Advantage plans were sicker than they actually were, officials said. U.S. Justice Department officials said the federal program makes larger payments for patients with more severe diagnoses.
“Health care providers who flout the law need to know that my office will hold accountable those who pad their bottom line at taxpayer expense,” Acting U.S. Attorney Stephanie Hinds for the Northern District of California said in a statement.
Moreover, Sutter didn’t do enough to correct the problem once it became aware that it had been submitting unsupported diagnosis codes, the officials said.
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That "diverts funds from this vital health care program, which is a disservice to patients needing care,” Steven Ryan, special agent in charge for the U.S. Department of Health and Human Services' inspector general said in a statement.
Sutter said it paid $30 million to partly resolve the claims in 2019 and will now pay the additional $60 million to fully resolve the lawsuit without admitting liability.
The total includes $60 million in restitution for the amount alleged to have been defrauded and a $30 million penalty.
Sutter also agreed to a five-year “corporate integrity agreement” that requires an outside group to review patients' medical records and diagnoses.
The settlement brings “closure to a long-running dispute, allowing Sutter to avoid the uncertainty and further expense of protracted litigation, and enabling a constructive relationship with the government as we work together” under the monitoring agreement, Sutter said in a statement.
Sutter has 24 hospitals, 36 outpatient surgery centers, and 16 cardiac and cancer centers.
The civil settlement resulted from a 2015 False Claims Act whistleblower complaint by former Sutter employee Kathleen Ormsby. Attorneys representing Ormsby said the problem took place from 2010 to 2016.
Ormsby and her attorneys will get between 15% and 30% of the settlement amount, with the amount still to be determined.
After Sutter hired Ormsby in 2013, she began comparing benefit codes with patients’ records. “What she found was just really, really high error rates on both sides, suggesting that ... Sutter was getting wildly overpaid,” said Kathleen Scanlan, Ormsby's attorney.
Instead of making corrections, Sutter shut down Ormsby's audit program, Scanlan said. Ormsby then determined that other affiliated medical practices were also “engaged in a program that was a campaign to increase their ... compensation from the government," Scanlan said.
Four of every 10 Medicare beneficiaries are now enrolled in Medicare Advantage plans, double the number of a decade ago, and it has now grown to a $350 billion market annually.
Under the program, also known as Medicare Part C, beneficiaries enroll in privately-run managed care plans that are paid by the government monthly based on the diagnosed health of the patient.
“That's a recipe for participants in the program to do what we allege Sutter did, which is to inflate these risk scores and make the patients seem sicker than they really are, so they get higher monthly payments," said Gordon Schnell, another of Ormsby’s attorneys.
The announcement comes days after a judge on Friday gave final approval to an unrelated 2019 settlement that required Sutter to pay $575 million. That settled allegations by the state attorney general and others that Sutter's anticompetitive practices led to higher costs for patients consumers in Northern California compared to elsewhere in the state.