When Coding Creativity Turns Criminal

As regular listeners to Monitor Monday know, my segments typically focus on cases alleging healthcare fraud against health insurance companies, hospitals, or physician groups, initiated by whistleblowers under the federal False Claims Act (FCA), which is a civil fraud statute. Today, however, I’d like to report on criminal charges that federal prosecutors in the Southern District of Florida recently brought against 39-year-old Kenia Valle Boza, who served as a former Coding Manager and Risk Adjustment Manager at Pasteur Medical Center in South Florida and Director of Medicare Risk Adjustment Analytics at HealthSun Health Plans, a Medicare Advantage Organization (MAO) in South Florida.    

Instead of being alerted to the alleged wrongdoing by a whistleblower, the government in this matter was informed by HealthSun, the MAO, which made a voluntary disclosure and also agreed to pay the Centers for Medicare & Medicaid Services (CMS) $53 million in overpayments. The fraud charges against Ms. Boza involve her alleged orchestration of a scheme to submit to Medicare false diagnosis codes for HealthSun beneficiaries for the types of chronic conditions that risk-adjust, thereby improperly increasing the amount of capitation payments HealthSun received from CMS. 

This indictment is the latest example of the U.S. Department of Justice (DOJ) pursuing its stated enforcement priority of prosecuting frauds involving Medicare Advantage and is part of a growing number of cases involving the alleged manipulation of risk scores to inflate CMS payments by making Medicare beneficiaries appear sicker than they actually are. In its February report on FCA settlements and judgments for the 2022 fiscal year, DOJ noted its pursuit of cases alleging that organizations participating in Medicare Part C knowingly submitted or caused the submission of inaccurate information, or knowingly failed to correct inaccurate information about the health status of beneficiaries enrolled in their plans, to increase reimbursement. Specifically, DOJ noted its intervention in a case against Cigna, which has since settled at the end of September for $172 million, and its litigation against UHG, Independent Health, Elevance Health, and the Kaiser Permanente consortium. 

Included in the indictment against Ms. Boza are allegations that she entered and caused others to enter into patients’ medical records diagnoses based on diagnostic tests that were not a proper basis for diagnosing those conditions. For instance, Ms. Boza is alleged to have entered and caused others to enter in patients’ medical records diagnoses of Other Hemaglobinopathies and Disorder of Carbohydrate Metabolism, both of which risk-adjust, based on the patients having elevated HAb1c test results, all the while knowing that those results were not a proper basis for diagnosing either of those conditions. 

While we have seen allegations similar to these in the Justice Department’s many other risk-adjustment fraud cases, seemingly unique in Ms. Boza’s case (and likely what led to the decision to pursue this matter criminally) are the allegations that she caused coders at Pasteur Medical Center to obtain the login credentials of certain physicians there, log into the electronic medical record (EMR) wrongfully, posing as those physicians, and enter unsupported risk-adjustment diagnoses, thereby evading detection and making it look like authorized physicians had added the improper risk-adjustment codes. 

The addition of even one chronic condition to a Medicare beneficiary’s medical chart can dramatically increase the amount a health plan receives from CMS under Medicare Part C for treating that patient. For unscrupulous health plans and their risk adjustment directors, the potential profits to be made from the addition of risk-adjusted diagnoses can prove irresistible, and lead to the type of flagrant behavior charged in this case, whereby coders allegedly were encouraged to pose as physicians and enter unsupported chronic conditions into patients’ medical charts, valued at tens of millions of dollars. As this case demonstrates, such behavior carries enormous risk, with Ms. Boza potentially facing over 30 years in prison if she is convicted of the charges in the current indictment.