{"id":54534,"date":"2023-10-26T19:24:08","date_gmt":"2023-10-27T02:24:08","guid":{"rendered":"https:\/\/cjnotebook.com\/?p=54534"},"modified":"2023-10-26T19:24:08","modified_gmt":"2023-10-27T02:24:08","slug":"former-executive-at-medicare-advantage-charged-in-multimillion-dollar-medicare-fraud-scheme","status":"publish","type":"post","link":"https:\/\/cjnotebook.com\/?p=54534","title":{"rendered":"Former Executive at Medicare Advantage Charged in Multimillion-Dollar Medicare Fraud Scheme"},"content":{"rendered":"

\"person<\/a>Federal authorities charged a former executive of HealthSun Health Plans Inc., a Medicare Advantage provider in South Florida, for her involvement in a multimillion-dollar Medicare fraud conspiracy.<\/span><\/p>\n

In addition, the Justice Department announced that it has\u00a0declined prosecution<\/a> of HealthSun after considering the factors outlined in the department\u2019s Principles of Federal Prosecution of Business Organizations and the Criminal Division\u2019s Corporate Enforcement and Voluntary Self-Disclosure Policy.<\/span><\/p>\n

This included HealthSun\u2019s prompt voluntary self-disclosure, cooperation, and remediation, as well as HealthSun\u2019s agreement to repay the Department of Health and Human Services\u2019 Centers for Medicare & Medicaid Services (CMS) about $53 million in overpayments.<\/span><\/p>\n

\"\"According to court documents, Kenia Valle Boza, 39, of Miami, formerly the Director of Medicare Risk Adjustment Analytics at HealthSun, allegedly orchestrated a scheme to submit false and fraudulent information to CMS.<\/span><\/p>\n

This was to\u00a0increase the amount that HealthSun received for certain Medicare Advantage enrollees.<\/span><\/p>\n

CMS pays Medicare Advantage plans like those HealthSun operates based, in part, on the health condition of their enrollees.<\/span><\/p>\n

To increase the company\u2019s profits and compensation, Valle and her co-conspirators allegedly submitted fraudulent information about chronic ailments that Medicare beneficiaries have in HealthSun\u2019s plans to CMS.<\/span><\/p>\n

\"\"Plans that they did not actually have and that non-healthcare providers, such as coders, added to patient health records, according to officials.<\/span><\/p>\n

For example, Valle and her co-conspirators allegedly entered and caused others to enter diagnoses into the medical records of beneficiaries enrolled in HealthSun\u2019s plans based on diagnostic tests that were not a proper basis for diagnosing those conditions.<\/span><\/p>\n

In addition, Valle and her co-conspirators allegedly obtained the login credentials assigned to certain physicians to access electronic medical records (EMR) wrongfully.<\/span><\/p>\n

This was done as physicians falsely and fraudulently entered chronic conditions directly into beneficiaries’ medical records.<\/span><\/p>\n

These diagnoses appeared to have been made by the physicians. However, coders entered the conditions into beneficiaries\u2019 medical records, often days or weeks after the physician saw the beneficiary, officials stated.<\/span><\/p>\n

As a result of the scheme, Valle and her co-conspirators allegedly caused HealthSun to submit tens of thousands of false and fraudulent diagnosis codes to CMS, resulting in CMS overpaying HealthSun millions of dollars.<\/span><\/p>\n

Valle is charged with one count of conspiracy to commit health care fraud and wire fraud, two counts of wire fraud, and three counts of major fraud against the United States.<\/span><\/p>\n

If convicted, Valle faces up to 20 years in prison on the conspiracy count and each wire fraud count, and up to 10 years in prison on each count of major fraud against the United States. <\/span><\/p>\n

Valle is presumed innocent unless proven guilty.<\/span><\/p>\n

Department of Health and Human Services and the FBI Miami Field Office are investigating the case.<\/span><\/p>\n

Assistant Chief John \u201cFritz\u201d Scanlon and Trial Attorney Alexander Thor Pogozelski of the Criminal Division\u2019s Fraud Section are prosecuting the case.<\/span><\/p>\n

\n
\n
Indictment<\/a><\/span><\/div>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

Federal authorities charged a former executive of HealthSun Health Plans Inc., a Medicare Advantage provider in South Florida, for her involvement in a multimillion-dollar Medicare fraud conspiracy. 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