Alerts1.23.23
False Claims Act Case May Proceed Against Medicare Advantage Organization, Subsidiaries
Highlights
A federal court recently interpreted the International Classification of Diseases (ICD) Guidelines to require that diagnoses added through addenda must have required or affected patient care or management at the encounter
Defendants conceded that the ICD Guidelines “have the force of law”
The Ross holding reinforces that MAOs and providers should have robust compliance programs to ensure that retrospective reviews and the use of addenda comply with CMS guidance
A decision earlier this month allowing a case to proceed regarding alleged fraud by a Medicare Advantage Organization (MAO) and its subsidiaries signals the continued scrutiny of certain risk-adjustment practices in the healthcare industry.
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