Recent Trends and New Areas of Focus in Risk Adjustment Enforcement

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Course Description

Join whistleblower attorney Liz Soltan to learn about recent developments in Department of Justice enforcement actions targeting Medicare risk adjustment fraud. Learn how the False Claims Act allows the federal government and whistleblowers to work together to pursue cases against companies and individuals that defraud Medicare. Ms. Soltan will provide an overview of recent False Claims Act cases as case studies on the many permutations of fraud in the Medicare Risk Adjustment space. Health insurers, providers, and vendors have all been defendants in these cases, and the fraud often involves adding or failing to delete unsupported diagnosis codes in order to inflate payments. Newer investigations have also looked into the role of illegal kickbacks. Gain insight into practices the government has investigated as risk adjustment fraud to understand what not to do, and hear Ms. Soltan’s predictions for continued hot enforcement areas.

Learning Objectives

• Become familiar with the False Claims Act and an overview of its history
• Understand the basic process of how False Claims Act cases proceed
• Learn how whistleblowers and the Department of Justice work together to investigate and prosecute fraud in False Claims Act cases
• Learn what practices the DOJ has found constitute Medicare risk adjustment fraud
• Understand the status of major risk adjustment fraud cases, including recent settlements and more detailed information on a few important cases
• Be introduced to a few risk adjustment fraud cases that involved criminal liability for individuals involved in the fraud
• Know likely future directions for risk adjustment fraud enforcement and predicted areas of focus

Areas Covered in the Session

• Brief introduction to the False Claims Act
• The life cycle of a False Claims Act case
• Introduction to use of the False Claims Act in the world of Medicare Advantage
• Trends in the types of allegations brought in Medicare Advantage False Claims Act cases – ex: fabricating diagnosis codes, looking for codes to add but not delete, pressuring providers to submit unsupported codes
• Recent trend: False Claims Act cases involving Medicare Advantage and kickbacks that violate the Anti-Kickback Statute
• Major settlements in Medicare Advantage False Claims Act cases
• Recent court decisions in these cases (including dismissals)
• Case study of 2 cases in this space
• Criminal cases arising from Medicare risk adjustment fraud
• Cases to watch and future enforcement subject matter predictions
• Live Q&A Session

Suggested Attendees

• Administrators, Especially Compliance Employees and Directors of Coding, At Medicare Advantage Organizations
• Healthcare Providers Serving Medicare Advantage Patients (and Administrative Staff for these Providers)
• Vendors for Medicare Advantage Organizations, Especially Those Providing Data Mining or Coding-Related Services
• Medical Coders

About the Presenter

Liz Soltan is an associate at the New York office of Whistleblower Partners LLP, a boutique law firm dedicated to representing whistleblowers under various U.S. whistleblower reward programs. She is a member of the case team working side-by-side with DOJ on United States ex rel. Poehling v. UnitedHealth Group, Inc., a pioneering Medicare Advantage risk adjustment fraud case launched by a Whistleblower Partners client. She also works on a major Medicare Advantage risk adjustment fraud case against Kaiser Permanente. In addition to healthcare fraud cases, Ms. Soltan represents whistleblowers in False Claims Act cases related to customs fraud. She also helps whistleblowers bring tips to government agencies (SEC, CFTC, FinCEN) regarding financial fraud, money laundering, and sanctions evasion.

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Additional Information

After Registration: You will receive an email with login information and handouts (presentation slides) that you can print and share with all participants at your location.

System Requirement:

• Internet Speed: Preferably above 1 MBPS
• Headset: Any decent headset and microphone which can be used to talk and hear clearly

Live Course Cancellation Policy: If for any reason Skillacquire need to cancel this program, Skillacquire will notify participants by email of the cancellation no less than 24 hours prior to the expected start time.

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For more information, you can reach out to the below contact:

Toll-Free No: 1-302-444-0162

Email: care@skillacquire.com 

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