A former executive at HealthSun Health Plans Inc. (HealthSun), operating Medicare Advantage plans in South Florida, has been charged by the Justice Department in connection with a multimillion-dollar Medicare fraud scheme. This case highlights the critical role and responsibilities of professionals in positions such as Advantage Care Coding Director and the severe consequences of fraudulent activities within Medicare Advantage organizations.
Kenia Valle Boza, 39, formerly the Director of Medicare Risk Adjustment Analytics at HealthSun, is accused of orchestrating a scheme to submit false information to the Centers for Medicare & Medicaid Services (CMS). This was allegedly done to inflate the payments HealthSun received for its Medicare Advantage enrollees. CMS payments to Medicare Advantage plans are partly determined by the health conditions of their enrollees, making accurate and ethical coding practices paramount.
According to court documents, Valle Boza and alleged co-conspirators knowingly submitted, or caused the submission of, false and fraudulent information regarding chronic ailments that HealthSun beneficiaries did not actually have. These false diagnoses were reportedly added to patient health records by non-healthcare providers, such as coders, under the direction of Valle Boza.
The Department of Justice seal, representing the agency that announced charges against a former HealthSun executive for Medicare fraud.
The scheme involved several fraudulent practices. It is alleged that diagnoses were entered based on tests that were not proper grounds for diagnosing those conditions. Furthermore, Valle Boza and others purportedly obtained physician login credentials to Electronic Medical Records (EMR). Using these credentials, they falsely entered chronic conditions directly into patient records, making it appear as though physicians had diagnosed and documented these conditions when, in fact, coders were responsible for the entries, often after the patient had been seen by a physician.
A representation of an Electronic Medical Records (EMR) interface, a key tool misused in the alleged fraud to falsely inflate patient health condition records.
This alleged scheme resulted in the submission of tens of thousands of false diagnosis codes to CMS, leading to millions of dollars in overpayments to HealthSun. While the Justice Department has declined prosecution of HealthSun due to their voluntary self-disclosure, cooperation, and agreement to repay approximately $53 million, the charges against Valle Boza underscore the individual accountability within corporate fraud cases.
Valle Boza faces serious charges, including conspiracy to commit health care fraud and wire fraud, wire fraud, and major fraud against the United States. Conviction could lead to a maximum penalty of 20 years in prison for conspiracy and each wire fraud count, and up to 10 years for each major fraud count.
This case serves as a stark reminder for advantage care coding directors and all professionals in healthcare compliance and risk management. Maintaining ethical coding practices, ensuring data integrity within EMR systems, and rigorous oversight are crucial to prevent fraud and protect the integrity of Medicare Advantage programs. The focus on voluntary self-disclosure and remediation by HealthSun also emphasizes the importance of proactive compliance measures and transparent cooperation when issues are identified. The ongoing investigation by HHS-OIG and the FBI Miami Field Office, along with prosecution by the Criminal Division’s Fraud Section, demonstrates the commitment to holding individuals accountable for healthcare fraud.
