fraud 4227099 640

Former Health Plan Risk Adjustment Director Indicted for Fraud Charges

29 Oct, 2023 F.J. Thomas

fraud 4227099 640

Sarasota, FL ( – Starting in 1996 Anthem, Inc was one of the largest healthcare companies in the U.S., offering medical coverage through its association and acquisition of Blue Cross Blue Shield plans. In 2022, the company announced their corporate name would be changing to Elevance Health, Inc. 

In 2017, Anthem purchased the south Florida network HealthSun, which offered Medicare Advantage Plans to beneficiaries. CMS Medicare pays Medicare advantage plans based on the health of the patients they are covering.  The Medicare Advantage plans file claims information to CMS with diagnosis information so they can determine what payment is due. To calculate risk, CMS groups certain diagnosis codes in categories called Heirarchical Condition Categories (HCCs), which generally include major, severe, and chronic conditions. CMS uses these groupings paired with patient demographic data to calculate their risk adjustment and the payments made to the health plans. 

In an announcement earlier this week by the Department Of Justice, HealthSun’s former Director of Medicare Risk Adjustment Analytics has been charged with one count of conspiracy to commit health care fraud and wire fraud, two counts of wire fraud, and three counts of major fraud related to improper filing of HCC diagnoses. 

Kenia Valle Boza, 39, of Miami was a certified AAPC coder, and worked for Pasteur Medical as a coding manager from 2015 to 2016, and then as the Medicare Risk Coding Manager from 2016 to 2017. Pasteur was a group of medical clinics located around Miami, and beginning in November 2016, HealthSun purchased Pasteur. Pasteur contracted with HealthSun to provide healthcare to their beneficiaries.  

From 2017 to January 2020, Valle worked for HealthSun as the Director of Medicare Risk Adjustment Analytics. According to the indictment, investigators assert that Valle, along with co-conspirators, falsely entered risk adjusted diagnoses into patient medical records. In order to do so, investigators contend that in some cases, Valle and other coding staff used physician log ins to make it appear that the physician had issued an inappropriate diagnosis for the patient. 

Investigators believe that the diagnoses entry was based on tests that were not a proper diagnosis for the conditions that were reported. As an example, one of the diagnosis codes highlighted in the indictment is E74.9, Disorder Of Carbohydrate Metabolism, Unspecified. As a result of up-coding of the diagnoses, investigators allege that the payments from Medicare to the health plan were increased by more than $12 million. 

If convicted, Valle could face up to 20 years in prison on conspiracy charges and on each wire fraud count, as well as 10 years for each count of major fraud. HealthSun will not be prosecuted due to their self-disclosure, cooperation, and agreement to repay $53 million in overpayments. 

What is somewhat curious about this case is that while prosecutors go into great detail in the indictment that they believe the motive of the conspiracy was financial gain, the only deposits listed went into HealthSun’s own bank accounts. Additionally, there is no mention of Valle’s own lavish liftstyle or extravagant assets mentioned. It will be interesting to see how this case progresses. 

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    About The Author

    • F.J. Thomas

      F.J. Thomas has worked in healthcare business for more than fifteen years in Tennessee. Her experience as a contract appeals analyst has given her an intimate grasp of the inner workings of both the provider and insurance world. Knowing first hand that the industry is constantly changing, she strives to find resources and information you can use.

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