Recently the Department of Justice announced that it would focus on healthcare fraud investigations on Medicare Part C (“Medicare Advantage”). Specifically, there will be investigations into Medicare Advantage fraud. Under traditional Medicare, Medicare pays providers for beneficiaries’ care on a fee for service model and beneficiaries can receive care from any provider that accepts Medicare. Medicare Advantage is an alternative that provides Medicare Parts A and B benefits and additional benefits not covered by traditional Medicare. Medicare Advantage enrollment has been increasing and as of 2023, 51% of eligible Medicare population are enrolled in a Medicare Advantage plan.

Medicare Advantage fraud is usually civilly enforced, but the DOJ is beginning to bring criminal charges against those perpetrating Medicare Advantage fraud. In October of this year in Miami, the DOJ Criminal Division’s Fraud Section brought federal criminal charges directly related to Medicare Advantage risk adjustment payment methodology. In this indictment, HealthSun Health Plans Inc.’s former director of Medicare risk adjustment, Kenia Boza, was charged with Conspiracy to Commit Health Care Fraud and Wire Fraud in violation of 18 U.S.C. § 1349, Wire Fraud in violation of18 U.S.C. §§ 1343 and 2, and Major Fraud Against the United States in violation of18 U.S.C. §§ 1031(a) and 2.The indictment alleges that those who enrolled in HealthSun’s Medicare Advantage Plan did not actually have the ailments that Boza claimed they did and that Boza used physicians’ login credentials to alter patient medical records to add fraudulent diagnoses. According to the indictment, Boza’s alleged conduct was part of a long-running scheme from around 2015-2020 and that $53 million in overpayments were made to HealthSun as a result. This indictment is the second time the DOJ has brought criminal charges for alleged Medicare Advantage fraud. In 2016, a primary care physician in Florida pled guilty to one count of Healthcare Fraud and was sentenced to 46 months in prison for falsely diagnosing over 300 Medicare Advantage beneficiaries to obtain excess fees from the Medicare Advantage plan.

Although the Medicare Advantage plans are usually civilly enforced, these plans operate nationwide, which opens up the possibility of criminal investigations to the other U.S. Attorneys’ offices. Additionally, with more people involved in Medicare Advantage plans than ever before, federal law enforcement scrutiny of it has increased significantly. Thus, it is incredibly important to understand what the possible federal criminal repercussions of Medicare Advantage fraud are.

When under investigation it is important to follow the advice of your attorney and not speak about the alleged crimes over social media. LGR Law, LLC’s federal criminal defense attorneys have the essential skills to protect your legal rights. Should you or a loved one receive any indication that you are a target of a federal investigation, contact Lorraine Gauli-Rufo, and the attorneys at LGR Law immediately. (973) 239-4300, www.lgrlawgroup.com, [email protected]