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Insurers Gaming Medicare Might Cost Washington Billions a Year

Health plans get paid more for covering sicker patients. Are they exaggerating how ill people really are?
relates to Insurers Gaming Medicare Might Cost Washington Billions a Year
Photographer: Gallery Stock

Two years ago, Anita Silingo accused health insurance companies of brazenly ripping off the government. Silingo, who worked at a company called MedXM that consulted for health insurance companies, filed a sealed whistleblower lawsuit claiming that MedXM exaggerated or outright fabricated illnesses to get its clients higher fees from Medicare. The Justice Department hasn't taken up the suit and the companies have sought to dismiss it in court. But new research suggests that the kind of inflated diagnoses Silingo described costs the government billions a year.

Silingo is one of a handful of whistleblowers who have come forward with claims that health plans have profited by illegally claiming patients are sicker than they are. According to her complaint, MedXM altered medical records to make diagnoses appear more severe and often created records without doing the face-to-face patient visits required by law. Health insurers, including Anthem, Health Net, and Molina, "all turned a blind eye to the truth in exchange for receiving" bigger Medicare payments, Silingo alleged. Representatives for the companies named declined to comment.