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Dive Brief:
- Philadelphia-based insurer Independence Blue Cross has agreed to pay $22.5 million to settle allegations it defrauded Medicare by knowingly submitting inflated diagnosis codes in Medicare Advantage, the Department of Justice announced Wednesday.
- The DOJ contends that the diagnosis codes made patients appear sicker than they actually were, a process called upcoding. As a result, the insurer allegedly received higher payments from Medicare than it was entitled to.
- IBX said it settled the case to avoid prolonged litigation, but did not admit wrongdoing. “This matter was not about the quality of care our members received. It involved differing views regarding certain documentation and reporting requirements under the Medicare Advantage risk adjustment program,” IBX said.
Dive Insight:
The settlement stemmed from a whistleblower complaint filed by a former IBX employee in 2020 alleging that the insurer raked in “tens of millions of dollars in payments” by upcoding.
In MA, the CMS pays organizations like IBX on a per-member basis, then adjusts payments based on the severity of the enrollee’s health conditions and other risk factors in a process called risk adjustment. Generally, sicker patients lead to higher payments.
However, the CMS relies on insurers to submit diagnosis codes, meaning the accuracy of the codes is crucial to ensuring proper payment amounts.
According to the DOJ, IBX ran a retrospective review program between 2016 to 2020 designed to identify additional diagnosis codes the insurer could submit to Medicare.
IBX hired nurses to review medical charts, but the company allegedly did not investigate or withdraw any inaccurate or unsubstantiated codes found during the review, which it is obligated to do under law.
Instead, IBX told the CMS that its data was “accurate, complete, and truthful,” the DOJ said, failing to acknowledge the cherry-picked nature of the findings.
The DOJ alleged that IBX violated the False Claims Act, the government’s chief anti-fraud law that holds individuals and companies liable for purposely defrauding federal programs.
“The government pays private insurers over $530 billion each year to care for Americans enrolled in Medicare Advantage,” Brett Shumate, assistant attorney general of the Justice Department’s civil division, said in the press release. “When insurers knowingly and improperly retain inflated payments based on inaccurate and untruthful diagnoses, we will hold them accountable whether they are a small regional plan or a large nationwide organization.”
Independence Blue Cross covers more than 2.2 million members across southeastern Pennsylvania, southern New Jersey and Delaware, making it one of the region’s largest insurers. It also covers an additional 3.1 million people nationwide through third-party plan administration and other services.
The civil settlement reached with IBX is far from the first of its kind — total healthcare fraud accounted for more than $5.7 billion of the $6.8 billion in False Claims Act settlements in fiscal year 2025, DOJ data shows.
Health plan affiliates of Kaiser Permanente settled for $556 million in January to resolve False Claims Act allegations stemming from upcoding in Medicare Advantage. UnitedHealth and Humana have also faced scrutiny for allegedly exaggerating the health needs of their members in MA.
The HHS Office of Inspector General, a federal watchdog, has filed multiple reports sounding the alarm about improper payments, upcoding and fraud in MA.
Meanwhile, the Medicare Payment Advisory Commission anticipates that the U.S. government is set to spend 14% more, or an additional $76 billion, this year on seniors in MA than it would if those same people enrolled in traditional Medicare, in part due to upcoding.
