A new whistleblower lawsuit accuses a California health care firm of diagnosing “false and fraudulent” medical conditions that several Medicare Advantage plans allegedly used to overcharge the federal government by $1 billion or more.
The suit was filed by Anita Silingo, a former compliance officer for Mobile Medical Examination Services, Inc., or MedXM. The Santa Ana, California-based firm sends medical professionals to the homes of Medicare Advantage members to assess their health.
Silingo claims she was fired last year after she tried to stop MedXM from exaggerating how sick these patients were, which raised government payments to the health plans. The suit, filed in August 2013 in California, was unsealed by a judge late last month.
The suit also names four Medicare Advantage insurance plans which, Silingo alleges, “turned a blind eye” to the practices. The health plans named in the suit are: Molina Healthcare of California; WellPoint, Inc., which operates Anthem Blue Cross and Blue Shield; Health Net of California, Inc. and Alameda Alliance for Health. None would comment.
MedXM chief executive officer Sy Zahedi called the allegations “categorically not true.” In a brief interview, Zahedi said: “I can’t comment on any litigation right now, but anybody is free to file a lawsuit.” He said the company was “just served (with the suit) a week ago. It is brand new to us. We look forward to our day in court.”
Whether her claims hold up in court or not, Silingo’s lawsuit is likely to draw further attention to government oversight of Medicare Advantage plans. The health plans, an alternative to standard Medicare, are mostly run by private insurance companies. They serve more than 15 million Americans, or about one in three elderly and disabled people on Medicare, at a cost to taxpayers that could reach $160 billion this year. The plans are paid based on a “risk score,” which estimates how sick patients are. Medicare pays higher rates for sicker patients.
Critics argue that federal officials waste billions of tax dollars every year by failing to crack down on health plans that game the arcane payment system. At least five other whistleblower cases accusing Medicare Advantage of fraudulently inflating risk scores are winding through federal courts, records show.
Silingo worked at MedXM from August of 2011 to June of 2013. Under federal Medicare regulations, a compliance officer’s job is to make sure that regulations are followed and any violations are corrected.
Silingo says she was fired after alerting her bosses to problems ranging from doctors who did implausibly large numbers of evaluations in a day to inaccurate blood tests that she said skewed diagnostic results.
“She noticed these types of things and complained to upper management, but they blew her off,” said her attorney, William K. Hanagami. He declined to make Silingo available for an interview.
Silingo cites problems with in-home health visits to Medicare Advantage patients in Ohio, New York, California, Texas, Oregon and Virginia.