Elevance Health must face federal suit alleging fraud

Indianapolis-based Elevance Health Inc. must face a federal lawsuit alleging that the company defrauded the U.S. government of millions of dollars by certifying incorrect diagnosis data from doctors and other health providers.

In a ruling announced this week, Judge Andrew Carter of the U.S. District Court for the Southern District of New York said Elevance—which was known as Anthem Inc. until a corporate rebranding in late June—failed to show the lawsuit should be dismissed for lack of materiality.

Carter said the total amount allegedly overpaid by the Centers for Medicare and Medicaid Services to Elevance could total well more than $100 million, making the government’s costs “substantial and not merely administrative.”

The U.S. Justice Department filed the civil fraud action against Elevance in March 2020

The complaint accuses Elevance, one of the nation’s largest providers of Medicare Advantage plans for seniors, of causing the Centers for Medicare and Medicaid Services to overpay the company based on inaccurate and inflated information between early 2014 and early 2018.

Medicare Advantage plans are health insurance policies for senior citizens, administered by private insurance companies under contract with Medicare. Under the program, the government pays private insurers a monthly amount to provide health care benefits for seniors.

The Medicare Advantage plans are hugely popular for their wide raft of benefits, with monthly premiums that are often lower than those of traditional Medicare.

Under the plans, Elevance provides health coverage for Medicare beneficiaries. In return, it received payments from the government based on the patients’ medical conditions and demographic factors.

The Justice Department sued Elevance under the federal False Claims Act and is seeking civil fines and triple damages.

The case is one of several Justice Department civil lawsuits against companies that participate in Medicare Advantage.