A Maine health care company will pay nearly $22.5 million to settle allegations it submitted false information to get inflated Medicare reimbursements.
Martin’s Point Health Care Inc., a Portland-based nonprofit, through its subsidiary, Martin’s Point GA, serves Medicare beneficiaries under Parts C and D in Maine and New Hampshire.
Between 2016 and 2019, Martin’s Point allegedly claimed beneficiaries suffered from conditions, including diabetes, morbid obesity, rheumatoid arthritis, drug or alcohol dependence, congestive heart failure and chronic obstructive pulmonary disorder, that were “unsupported, unsubstantiated, and invalid” based on their medical records, according to the U.S. Department of Justice, which announced the settlement Monday.
Those false claims, which the U.S. government alleges Martin’s Point submitted “knowingly,” inflated “risk scores” for beneficiaries and caused the nonprofit to receive larger “risk-adjusted payments” from the Centers for Medicare and Medicaid Services.
Under the Medicare Advantage program, organizations are paid more for serving beneficiaries with greater health problems.
The allegations were brought forward by a whistleblower, Alicia Wilbur, a former manager in Martin’s Point’s risk adjustment operations group, the Department of Justice said Monday.
“The government expects those who participate in Medicare Advantage to provide accurate information to ensure that proper payments are made for the care received by enrolled beneficiaries,” said Deputy Assistant Attorney General Michael D. Granston of the Justice Department’s Civil Division, Commercial Litigation Branch. “Today’s result sends a clear message to the Medicare Advantage community that the United States will take appropriate action against those who knowingly submit inflated claims for reimbursement.”
Since 2019, Martin’s Point has made a number of leadership and personnel changes, including changes to its board of directors, according to the Department of Justice.
As a result of the settlement, Martin’s Point will pay $22,485,000 to resolve the allegations of improper billing. Of that sum, $3.8 million will go to Wilbur.
The settlement is neither an admission of liability nor guilt by Martin’s Point.