US sues Kaiser Permanente over alleged Medicare fraud


SAN FRANCISCO (AP) — The federal government has sued Kaiser Permanente, alleging the health care giant committed Medicare fraud and pressured doctors to list incorrect diagnoses on medical records in order to receive higher reimbursements, officials said Friday.

The U.S. Department of Justice lawsuit, filed Thursday in federal court in San Francisco, consolidates allegations made in six whistleblower complaints.

Kaiser, based in Oakland, California, is a consortium of entities that together form one of the largest nonprofit health care plans in the U.S. with more than 12 million members and dozens of medical centers.

The lawsuit said Kaiser entities gamed the Medicare Advantage Plan system, also known as the Medicare Part C program, which gives beneficiaries the option of enrolling in managed care insurance plans, according to a statement from the U.S. Department of Justice.

The lawsuit contends that Kaiser “pressured its physicians to create addenda to medical records,” often months or more than a year after an initial consultation with an enrollee, because more severe diagnoses for beneficiaries generally result in larger payments to the plan.

“The integrity of government health care programs must be protected,” Stephanie Hinds, acting U.S. attorney for the Northern District of California, said in the statement. “The Medicare Advantage Program maintains the health of millions, and wrongful acts that defraud the program cannot continue and will be pursued.”

Kaiser defended its practices and called the lawsuit filing disappointing.

Kaiser Permanente’s mission is to provide high-quality, affordable health care services to improve the health of our members and the communities we serve. 

We are confident that Kaiser Permanente is compliant with Medicare Advantage program requirements and we intend to strongly defend against the lawsuits alleging otherwise.  

Our medical record documentation and risk adjustment diagnosis data submitted to the Centers for Medicare & Medicaid Services comply with applicable laws and Medicare Advantage program requirements. Our policies and practices represent well-reasoned and good-faith interpretations of sometimes vague and incomplete guidance from CMS. For nearly a decade, Kaiser Permanente has achieved consistently strong performance on Risk Adjustment Data Validation audits conducted by CMS. With such a strong track record with CMS, we are disappointed the Department of Justice would pursue this path. 

While Kaiser Permanente plans to vigorously defend against these allegations, we will not allow this litigation to distract from our mission. Our dedicated health care teams will remain focused on continuing to provide our patients and members with leading-edge treatment, prevention, and the whole-person care that is the cornerstone of our integrated health system.

Kaiser Permanente

The lawsuit names Kaiser Foundation Health Plan Inc.; Kaiser Foundation Health Plan of Colorado; The Permanente Medical Group Inc.; Southern California Permanente Medical Group Inc. and Colorado Permanente Medical Group P.C.

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