This email from Kip Sullivan is really really worth reading.

Sent from my iPhone

Begin forwarded message:

From: Kip <kiprs@usinternet.com>
Date: March 9, 2023 at 4:47:55 AM PST
To: One Payer States <onepayerstates@googlegroups.com>
Subject: One Payer States: How MA plans upcode



This complaint by the Dept of Justice against Kaiser Permanente is very helpful in understanding how Medicare Advantage plans upcode. https://www.justice.gov/opa/press-release/file/1444936/download You only need to read the “preliminary statement” (it runs through page 4) to understand how aggressively Kaiser upcodes. 

The DOJ filed its complaint in the federal court for Northern California in October 2021. The case began, however, with a complaint filed in the same court in 2013 by Ronda Osinek, a “Data Quality Trainer and Audit Manager at Kaiser’s San Rafael, California facility.” Because Osinek was the first of six whistle blowers to file, the case bears her name — United States Ex rel. Osinek v. Kaiser Permanente et al. 

A second complaint was filed in 2014 by Dr. James Taylor in 2014. Dr. Taylor had (has?) an excellent perch within Kaiser to observe Kaiser’s shenanigans. According to the DOJ’s complaint, “Dr. Taylor worked for Defendant Colorado Permanente Medical Group from 1995 through 2015, most recently as the Medical Director of Revenue Cycle/Claims, where his responsibilities included revenue cycle risk adjustment programs and coding governance and compliance. Dr. Taylor also previously served as Chair of the Board of Directors of Defendant Colorado Permanente Medical Group.” Dr. Taylor apparently made numerous efforts to get the Kaiser brass to stop defrauding Medicare before he went to court.

Four more whistleblowers filed complaints after 2014. Last December the court dismissed all or most of the last four complaints on the basis of the “first to file” rule. Apparently federal whistleblower law limits complainants to those who file first. Apparently Dr. Taylor’s complaint survived because he presented facts supporting allegations of a form of fraud different from the form Osinek’s complaint alleged.

God knows how much money Kaiser has wasted in its pursuit of profit at Medicare’s expense. You’ll see from the DOJ complaint Kaiser forced employees throughout its empire to  participate in the upcoding scheme. Kaiser has a National Medicare Finance Department, a sprawling Risk Adjustment Team, and regional risk adjustment teams, representatives of which are required to assemble twice a year to conspire (see p 9 of the complaint).

If you read articles about the suit, you’ll be impressed with how much time lawyers for the DOJ and Kaiser have spent drafting motions. And this case still hasn’t gone to trial ten years after Osinek filed her complaint. And all this for what? So capitated intermediaries can plunder the Medicare trust funds.

Kip– 
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