The DOJ Says A Data Mining Company Fabricated Medical Diagnoses To Make Money

Abstraction: DOJ charges data mining firm with fabricating Medicare diagnoses for profit

Key points:

• The DOJ filed civil fraud charges against DxID (medical analytics company) and Independent Health Association of Buffalo for Medicare Advantage billing fraud
• Medicare Advantage uses a "risk score" formula — higher scores for sicker patients yield more government payment; DxID combed EHRs to find "missed diagnoses" and pocketed up to 20% of new revenue generated
• DxID allegedly submitted thousands of unsupported condition codes from 2010–2017, generating tens of millions in improper charges
• Example fraud: billing for "major depression" in a patient whose doctor described him as having an "amazingly sunny disposition"
• This is the first federal action targeting a data mining company (not just an insurer) for Medicare Advantage gaming
• Whistleblower Teresa Ross filed the original 2012 suit; Kaiser Foundation Health Plan of Washington (formerly Group Health) settled for $6.3M in 2020; prior Medicare Advantage fraud settlements totaled over $300M

Connections: Department Of Justice · Dxid · Data Mining · Healthcare Fraud · Algorithmic Accountability

Source: https://www.npr.org/sections/health-shots/2021/09/14/1036776812/medicare-advantage-fraud-data-mining