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What day is National Report Medicare Advantage Fraud Day celebrated? April 24

What is National Report Medicare Advantage Fraud Day? This national day bring attention to Medicare Advantage fraud and informs the public that huge whistleblower rewards are possible for reporting Medicare Advantage fraud, which is sometimes referred to as Medicare risk adjustment fraud.

Who created the day? Former Department of Justice Attorney Joel D. Hesch created National Report Medicare Advantage Day to help whistleblowers stamp out Medicare fraud and get a reward in the process.

After more than 15 years of working in the DOJ whistleblower reward office in Washington D.C., and working on fraud cases recovering over $1.5 billion dollars, Mr. Hesch formed his own law firm dedicated solely to helping whistleblowers file rewards under government reward programs. The Hesch Firm, LLC exclusively represents whistleblowers file for whistleblower rewards they deserve. In fact, unless you hire an attorney and file the reward application correctly, whistleblowers are not eligible for a reward. Visit Mr. Hesch’s website for more details about whistleblower reward programs. You can ask Mr. Hesch to review in complete confidence your allegations of fraud against the government by filling out a form on his website and find out if he believes you have the right type of case eligible for a significant whistleblower reward and if he can represent you in filing for the reward.

How to celebrate? There are three ways to celebrate National Medicare Advantage Fraud Day. First, become aware that the government has a whistleblower reward program for reporting Medicare fraud. Second, contact an experienced whistleblower reward attorney to find out if you have the right type of case eligible for a reward. Third, tell others of National Medicare Advantage Fraud Day so they too can help put an end to Medicare fraud.

How to Report Medicare Advantage Fraud for a reward? The government pays whistleblower rewards for reporting fraud against Medicare, such as Medicare Advantage fraud. To claim a reward, you must use an attorney, such as Mr. Hesch, and file a particular reward application under seal in a legal proceeding.  

Under the Department of Justice (DOJ) reward program, which pays whistleblower rewards of between 15% to 25% of the amount DOJ recovers. The average DOJ reward for reporting Medicare fraud is $690,000 and some rewards have been as high as $150 million in a single case! In addition, if you Medicare report fraud under the DOJ program, the government must open an investigation and inform you of the results. Thus, applying for a reward is the only way to ensure an investigation takes place (rather than just calling a hotline). Today, over three-fourths of the government’s Medicare fraud cases are DOJ whistleblower reward cases. Thus, the government is counting on whistleblowers to bring Medicare fraud cases to DOJ and receive a reward in the process.

How to Report Medicare Advantage Fraud to CMS without seeking a rewardIf you do not want a reward, you can report the fraud directly to the Centers for Medicare & Medicaid Services (CMS), which runs the Medicare program. The downside by reporting the fraud to CMS is that the reward is limited to $1,000 rather than the DOJ program that pays up to 25% with no limit or cap. You can report fraud directly to CMS through its website or by calling its hotline.

Here is a link to the CMS website:

Here is a link to the CMS hotline: 1-800-MEDICARE (1-800-633-4227).

Overview of Medicare Advantage Fraud Schemes:

Medicare allows people to choose between (1) the “fee-for-service” plan where they go to any doctor and Medicare pays the healthcare provider a set fee based on each healthcare service provided, and (2) Medicare Advantage plan, where Medicare pays private health plans a monthly fee for each Medicare recipient they enroll regardless of how many times they receive medical treatment. A common model using this type of a system is an HMO.

In an attempt to reduce fraud and more fairly pay Medicare Advantage plans their true costs for treating Medicare patients or Medicare recipients, Medicare came up with a complicated payment plan that pays different amounts to different Medicare Advantage plans. Medicare came up with a risk adjustment formula that pays more funds to Medicare Advantage plans that have a higher risk of treating Medicare patients that likely will need more healthcare services per month.

With respect to Medicare Advantage plans, Medicare makes a risk adjustment to determine the fee to pay for each Medicare recipient enrolled in a Medicare Advantage plan. Before Medicare began using risk assessments, many HMOs or Medicare Advantage plans tried to cheat or defraud the system by only enroll healthy people and discouraging or barring higher risk patients from joining, such as pregnant women or those with medical conditions. Today, the amount of payment to Medicare Advantage plans is adjusted based upon the health risks of those enrolled. However, Medicare Advantage has its own fraudulent schemes.

Prior to 2003, risk adjustment payments to the Medicare Advantage health plans were based on simple demographics, such as gender, age and zip code. Today, the risk adjustment is based on complex formulaic calculations, which means that there are plenty of opportunities for Medicare Advantage plans to cheat or defraud Medicare.

Examples of Medicare Advantage Fraud

There are many ways in which Medicare Advantage plans are cheating and defrauding Medicare. Anytime a Medicare Advantage plan provides risk-adjustment data to Medicare via the Centers for Medicare & Medicaid Services (CMS) that is inaccurate it is Medicare Advantage fraud. There are a host of other fraudulent schemes by Medicare Advantage plans, such as Upcoding fraud, Chart Review fraud, and Chart Mining fraud.

Coding guidelines applicable to Medicare Advantage plans requires at least the following three things: (1) billing only based upon face to face visits, (2) documentation must show how chronic condition is being treated, managed or assessed, and (3) each diagnosis must have an assessment and a plan. If any one of these are missing, it is Medicare Advantage plan fraud.

Upcoding fraud is a form of risk-adjustment fraud by Medicare Advantage plans because it exaggerates the severity of each of the Medicare Advantage plan members’ condition so that it appears that this Medicare Advantage plan should get an increased risk factor and more monthly payments. The Medicare Advantage plan fraudulently creates a higher risk score or larger risk multiplier in order to fraudulently increase the amount of the “per member per month” (pm/pm) capitation rate Medicare pays.

Chart review fraud is another form of risk-adjustment fraud by Medicare Advantage plans. Medicare requires that Medicare Advantage plans bill based upon face to face visits. When administrative people change or alter the bills or medical records or charts it is fraud because they were not based on a face to face visit by a healthcare provider. Is it also fraud because there is not documentation to show how the chronic condition is being treated or assessed, but was inputted based upon codes and rates to increase Medicare reimbursement. 

There are many companies or outside vendors advertising to help conduct “chart audits,” “chart review services,” or “chart mining” and promise to help Medicare Advantage plans increase Medicare reimbursement. Unfortunately, many of these risk-adjustment data submission services (such as claims filtering) or chart review companies fraudulently upcode or only correct errors that increase payment and ignore or fail to correct errors that would decrease reimbursement. It is fraud when the Medicare Advantage plans change codes that are not based upon the healthcare providers’ face to face visits or fully documented to show how chronic conditions are being treated, managed or assessed and supported by an assessment and a plan.

It is also Medicare Advantage plan fraud to ask coders to adjust the codes based on other evidence in medical charts beyond the doctors’ documentation, such as based on what medications were prescribed or what laboratory test were order.

Free E-Book for reporting Medicare fraud. To help whistleblowers properly report Medicare Advantage fraud (or any Medicare fraud), Mr. Hesch authored a free e-book on obtaining rewards for reporting fraud against the government. You can also go directly to Mr. Hesch’s website to start the process of filing for a whistleblower reward (