The U.S. Department of Justice announced that Independence Blue Cross has agreed to pay USD 22.5 million to resolve False Claims Act allegations that it retained inflated Medicare Advantage payments based on inaccurate diagnosis codes. The government alleged that the insurer knowingly failed to withdraw unsupported codes and repay the Centers for Medicare & Medicaid Services, while falsely certifying that its diagnosis data was accurate. For payment years 2017 through 2021, Independence Blue Cross used nurse reviews of medical records to identify additional diagnoses that could increase risk adjusted payments. The government alleged that the insurer used those reviews to seek additional payments but did not remove previously submitted codes when the same reviews failed to substantiate them, which would have required reimbursement to Medicare. The settlement resolves a whistleblower lawsuit brought by a former Independence Blue Cross employee, who will receive USD 3.825 million. The resolved claims are allegations only, and there has been no determination of liability.
U.S. Department of Justice reaches USD 22.5 million Medicare Advantage overpayment settlement with Independence Blue Cross
Independence Blue Cross will pay USD 22.5 million to resolve U.S. Department of Justice allegations that it retained inflated Medicare Advantage payments based on unsupported diagnosis codes. The insurer allegedly used chart reviews to seek additional payments while failing to withdraw codes those reviews did not substantiate. The settlement includes a USD 3.825 million whistleblower award and does not constitute a determination of liability.