Medicare Advantage plans commit fraud when they knowingly submit — or have a contractor submit on their behalf — risk-adjustment data to the Centers for Medicare & Medicaid Services (CMS) that are inaccurate or ineligible for payment under CMS rules.
In many cases, Medicare Advantage fraud occurs by claiming risk-adjustment payments for medical conditions that their members were not treated for and may not even have. Program of All-Inclusive Care for the Elderly (PACE) plans also can cheat Medicare in that same way.
Whistleblowers can play an important role in stopping Medicare Advantage fraud so that funds are being used properly to care for the roughly one-third of Medicare beneficiaries who receive their benefits through the Medicare Advantage program, or Medicare Part C.
Risk-adjustment fraud violates the False Claims Act and could be investigated and stopped if a whistleblower files a “qui tam” (whistleblower) lawsuit. If the government recovers any funds as a result of the qui tam lawsuit, the whistleblower will receive a reward.