Another whistleblower suit alleges Medicare Advantage fraud

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.

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Copyright 2014 The Center for Public Integrity. This story was published by The Center for Public Integrity, a nonprofit, nonpartisan investigative news organization in Washington, D.C.