This is largest whistleblower settlement involving claims of risk adjustment fraud to date. Pagidipati has agreed to pay $750,000 to resolve his alleged role in the schemes. has been awarded an overall rating of 4.5 Stars based on Centers for Medicare and Medicaid Services’ (CMS) Star Rating methodology, which is a measure of overall health plan performance. The defendants allegedly lied about the sufficiency of their network of doctors, clinics, and hospitals available to serve their enrollees in the expanded service areas when, in fact, they had no such networks in place.Īccording to the terms of the settlement, Freedom Health and Optimum Healthcare will pay the government $16.7 million to resolve the allegations of risk adjustment fraud and $15 million for the allegedly fraudulent expansion of their service areas. Freedom Health in Florida receives a 4.5 Star Medicare Quality rating for 2023. The complaint also alleges that Freedom and Optimum, with the assistance of former Freedom COO Siddhartha “Sidd” Pagidipati, fraudulently induced the Centers for Medicare & Medicaid Services (CMS) to allow them to expand their health insurance offerings into new counties in Florida and the Carolinas. According to the complaint, Freedom and Optimum fraudulently inflated patient risk scores and the corresponding risk adjustment payments by claiming that their members were treated for conditions they either did not have or for which they were not treated. The higher the patient’s risk score, the higher the payments from Medicare. Medicare Advantage plus Prescription Drug plans are an. Risk adjustment permits Medicare to make additional payments to managed-care plans based on the plan members’ health-risk scores, which are derived from patients’ medical diagnoses. plans offer Medicare Advantage Prescription Drug plan coverage. The first scheme allegedly involved the gaming of a feature of the Medicare Advantage program known as risk adjustment, or risk scoring. Sewell’s whistleblower complaint, which was unsealed yesterday, alleges that Freedom and Optimum orchestrated two lucrative schemes. Sewell rose through the ranks, he became familiar with the companies’ various schemes to bilk money from the government-and felt compelled to do something about it.ĭr. Sewell, M.D, who worked at Freedom and Optimum from 2007 to 2012. The lawsuit was brought under the False Claims Act by the late Dr. Darren D. This is the largest whistleblower settlement to date for claims of risk adjustment fraud at $16.7 million of the $32.5 million total settlement amount. Patel and based in Tampa, Florida, to resolve allegations of systemic Medicare and Medicaid fraud. I attribute this high Star Ratings to the collaborative relationships we have had with the care providers in our network.Yesterday, the Department of Justice and Constantine Cannon, LLP announced that they had reached a settlement with Freedom Health and Optimum Healthcare, two large health insurers and operators of Medicare managed healthcare insurance plans controlled by Dr. Ensure positive member experiences with their health plan.Assist members in managing chronic conditions Get affordable plans to fit your life and budget with 0 premiums and low copays, plus extra benefits like dental, vision, and.Medicare Advantage plans are rated on their ability to: The Centers for Medicare & Medicaid Services awarded the company’s 2022 Medicare Advantage plans a 4.5-Star rating, with five stars being the best rating,” said Juan Carlos “JC” Doitteau, President at Insurance Pro. Even if a plan’s monthly premium is $0, you would still pay the Original Medicare Part B premium, and Part A premium if applicable, to have medical coverage. These plans’ prescription drug component helps cover medications. These plans help cover the costs of services provided by hospitals, doctors, lab tests and some preventive screenings. Medicare Advantage plans are an alternative way to get your Original Medicare. plans offer Medicare Advantage Prescription Drug plan coverage to Florida residents. Insurance Pro Provides Ongoing Training to its Insurance Agentsįreedom Health, Inc.ACCESS Florida Certified Community Partner.Special Enrollment Periods (SEP) for ACA.How to Get Medicare and Medicaid in Florida?.Is a Medicare Advantage Plan Right for You?.
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