The Justice Department has recently charged a former executive at HealthSun Health Plans Inc., a Medicare Advantage organization in South Florida, for her involvement in a multimillion-dollar Medicare fraud scheme. The former executive, Kenia Valle Boza, allegedly orchestrated a scheme to submit false and fraudulent information to CMS to increase the amount that HealthSun received for certain Medicare Advantage enrollees. This fraudulent activity resulted in CMS overpaying HealthSun millions of dollars. Valle is now facing charges of conspiracy to commit health care fraud and wire fraud, wire fraud, and major fraud against the United States. If convicted, she could face up to 20 years in prison.
Former Executive Charged in Multimillion-Dollar Medicare Fraud Scheme
The Justice Department has announced charges against a former executive at HealthSun Health Plans Inc. for her involvement in a multimillion-dollar Medicare fraud scheme. The charges allege that Kenia Valle Boza, the former Director of Medicare Risk Adjustment Analytics at HealthSun, orchestrated a scheme to submit false and fraudulent information to CMS in order to increase the amount that HealthSun received for certain Medicare Advantage enrollees.
Charges against Former Executive
Kenia Valle Boza, 39, of Miami, is accused of manipulating health condition records to increase Medicare Advantage payments for HealthSun. Medicare Advantage plans operate based on the health condition of their enrollees, and CMS pays these plans accordingly. Valle and her co-conspirators are alleged to have submitted false and fraudulent information about chronic ailments, which the beneficiaries did not actually have, to CMS. Non-health care providers, such as coders, were involved in adding these diagnoses to patient health records.
Declined Prosecution of HealthSun
The Justice Department has decided not to prosecute HealthSun after considering several factors, including the company’s prompt voluntary self-disclosure, cooperation, and remediation efforts. HealthSun has also agreed to repay approximately $53 million in overpayments to CMS. This decision is in accordance with the department’s Principles of Federal Prosecution of Business Organizations and the Criminal Division’s Corporate Enforcement and Voluntary Self-Disclosure Policy.
Alleged Scheme to Submit False and Fraudulent Information
The objective of the alleged scheme was to increase profits and compensation for HealthSun and its co-conspirators. By knowingly submitting and causing the submission of false and fraudulent information about chronic ailments, the individuals involved aimed to inflate the company’s profits. Non-healthcare providers, such as coders, played a role in adding these false diagnoses to patient health records.
Increase in Profits and Compensation
The motivation behind the scheme was to increase profits and compensation for HealthSun and its co-conspirators. The false and fraudulent information submitted about chronic ailments resulted in higher CMS payments to HealthSun. CMS pays Medicare Advantage plans based on the health condition of their enrollees. By falsely inflating the diagnoses of chronic conditions, HealthSun received greater payments from CMS.
False and Fraudulent Information about Chronic Ailments
Examples of false diagnoses entered into medical records include adding chronic conditions based on diagnostic tests that were not a proper basis for diagnosing those conditions. The scheme involved adding chronic conditions to patient health records without proper physician verification. This allowed for the submission of false and fraudulent information to CMS, resulting in inflated payments to HealthSun.
Unauthorized Access to Electronic Medical Records
Valle and her co-conspirators allegedly obtained the login credentials assigned to certain physicians, allowing them to access electronic medical records (EMR) without authorization. They then falsely and fraudulently entered chronic conditions directly into the medical records of beneficiaries, misrepresenting the physicians as the source of the diagnoses. This manipulation of EMR contributed to the submission of false and fraudulent information to CMS.
Submission of False and Fraudulent Diagnosis Codes
As a result of the scheme, Valle and her co-conspirators caused HealthSun to submit tens of thousands of false and fraudulent diagnosis codes to CMS. These codes led to overpayments from CMS to HealthSun, totaling millions of dollars. The impact of the scheme resulted in improper payments made by CMS to HealthSun based on the false and fraudulent information submitted.
Charges and Potential Penalties
Kenia Valle Boza is facing charges of conspiracy to commit health care fraud and wire fraud, wire fraud, and major fraud against the United States. If convicted, she could face a maximum penalty of 20 years in prison for conspiracy and wire fraud, and a maximum penalty of 10 years for major fraud against the United States. The severity of these charges reflects the seriousness of the alleged scheme and its impact on Medicare.
Announcement of Charges and Investigation
The charges against Kenia Valle Boza were announced by the Justice Department. The investigation into the Medicare fraud scheme involved the Criminal Division, HHS-OIG, and the FBI Miami Field Office. These agencies collaborated to uncover and prosecute the alleged fraud, ensuring the integrity of the Medicare program and holding those responsible accountable for their actions.