Home Medizin Großes US-amerikanisches Netzwerk für medizinische Grundversorgung wird wegen Medicare-Betrugs angeklagt

Großes US-amerikanisches Netzwerk für medizinische Grundversorgung wird wegen Medicare-Betrugs angeklagt

von NFI Redaktion

A Maryland-based company overseeing the nation’s largest independent network of primary care medical practices is facing a whistleblower lawsuit alleging it defrauded Medicare of millions of dollars by using „manipulated“ billing software to make patients appear sicker than they actually were.

In the civil lawsuit, Aledade, Inc. is accused of increasing its revenues improperly by inserting inflated medical diagnoses into patients‘ electronic health records through billing apps and other software provided to physicians. The lawsuit alleges that Aledade went to great lengths to make patients appear sicker than they actually were.

For example, Aledade allegedly merged anxiety with depression diagnoses, potentially leading to $3,300 per patient per year in increased payments. Additionally, the company classified patients over 65 who reported consuming more than one drink per day as having substance issues, potentially resulting in an additional $3,680 per patient, according to the lawsuit.

The whistleblower case was filed by Khushwinder Singh in January 2021 in a federal court in Seattle, but remained under seal until recently. Singh, a former senior medical director for risk and wellness products at Aledade, claims he was terminated after raising objections to the company’s „fraudulent behavior.“ Aledade has not yet filed a legal response in court. Julie Bataille, Aledade’s Senior Vice President of Communications, denied the allegations, stating in an interview that „the entire case is completely baseless and unfounded.“

Aledade, headquartered in Bethesda, Maryland, helps oversee independent clinics and primary care physician practices in over 40 states serving approximately 2 million people. The company is valued at $3.5 billion and has received significant venture capital funding.

The lawsuit against Aledade also names 19 independent medical practices as defendants, many in small towns across various states, alleging they knowingly used Aledade’s software to trigger fraudulent billing practices known as „upcoding.“ Multiple whistleblower lawsuits have targeted Medicare health plans for billing medical conditions not supported by patient records, resulting in substantial penalties.

This lawsuit appears to be the first to specifically accuse Accountable Care Organizations like Aledade of upcoding, a practice at odds with their mission to prevent wasteful spending in healthcare. ACOs have recently gained attention for their role in uncovering Medicare fraud and promoting cost savings initiatives.

The lawsuit accuses Aledade of manipulating coding software and providing guidance to physician practices within its network. The company allegedly encouraged doctors to edit suspicious medical diagnoses for additional payments, referring to it as „finding the ‚gravy‘ sitting in the… [patient’s] chart.“

Aledade reportedly instructed providers to diagnose complications of diabetes even when the patient’s diabetes was under control or the complicating factor no longer existed. Some practices in Delaware, North Carolina, and West Virginia allegedly billed the exaggerated code for over 90% of their Medicare Advantage patients with diabetes.

The lawsuit also states that Aledade manipulated the software to convert the diagnosis of „overweight“ to „morbid obesity,“ potentially increasing payments by $2,500 per patient. Providers were reportedly coding morbid obesity in traditional Medicare patients at ten times the national average.

Aledade issued a statement asserting that its software provides data and guidance to assist physicians in patient assessment and treatment, emphasizing that physicians remain solely responsible for medical decisions. The company pledged to continue advocating for changes to improve Medicare’s risk adjustment process while reducing administrative burden.CriticalSectionThe Justice Department notified the Seattle court in January that it would not intervene at the current time in the case, resulting in the unsealing of the case. Under the False Claims Act, whistleblowers can pursue the case independently. Singh argues in his complaint that unsupported diagnosis codes were added during annual wellness visits, without leading to additional medical care for patients.

The lawsuit also alleges that Aledade monitored doctors‘ coding practices closely through initiatives like the „No Diagnosis Left Behind“ program and maintained Slack channels where physicians could discuss financial incentives for adding higher-paying diagnosis codes.

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