The Justice Department announced charges against a former executive at HealthSun Health Plans Inc., a Medicare Advantage organization that operates Medicare Advantage plans in South Florida, for her role in a multimillion-dollar Medicare fraud scheme. In addition, the Justice Department announced that it has declined prosecution of HealthSun after considering the factors set forth in the department’s Principles of Federal Prosecution of Business Organizations and the Criminal Division’s Corporate Enforcement and Voluntary Self-Disclosure Policy, including HealthSun’s prompt voluntary self-disclosure, cooperation, and remediation, as well as HealthSun’s agreement to repay the Department of Health and Human Services’ Centers for Medicare & Medicaid Services (CMS) approximately $53 million in overpayments.
According to court documents, Kenia Valle Boza, 39, of Miami, formerly the Director of Medicare Risk Adjustment Analytics at HealthSun, allegedly orchestrated a scheme to submit false and fraudulent information to CMS to increase the amount that HealthSun received for certain Medicare Advantage enrollees. To increase the company’s profits and their own compensation, Valle and her co-conspirators are alleged to have knowingly submitted and caused the submission to CMS of false and fraudulent information about chronic ailments that Medicare beneficiaries in HealthSun’s plans did not actually have, and that non-healthcare providers, such as coders, added to patient health records.
