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SYSTEM SHOCK (2018)1/20/2024 ![]() “Inaccurate diagnosis codes distort both the delivery of health care and government payment for that health care.” Easton, an attorney who represented Wilbur. “Medicare Advantage programs rely on accurate health information to provide the best health care and proper payment from the federal government,” said Amy L. It also offers a Medicare Advantage plan that covers about 60,000 members.įrom 2016 to 2019, Martin’s Point assigned additional diagnoses to patients in order to get higher reimbursements using information that was not supported by medical records, Wilbur alleged in her complaint. Martin’s Point provides primary care to patients at six locations: Portland, Biddeford, Brunswick, Scarborough, Gorham and Portsmouth, New Hampshire. “Martin’s Point repeatedly pressured and directed employees and contractors to ignore unsupported codes – such as coding historical conditions as active – because deleting those codes would hurt profitability,” the complaint alleges. Medicare Advantage is a replacement insurance plan for patients who have Medicare coverage – typically those 65 and older – that covers costs standard Medicare doesn’t pay for, such as vision, hearing and dental, and may offer lower out of pocket costs for other services. That generated additional revenue for the nonprofit that it was not entitled to receive from the Medicare Advantage program. Martin’s Point would routinely code patients’ historical health conditions – such as for cancers, strokes and heart conditions – as active conditions, according to court records. Attempts to reach Wilbur through her attorney were unsuccessful Monday. Wilbur informed her superiors numerous times about inflated payments for Medicare services, but she was rebuffed, according to court documents that detail problems with the billing that date to 2013. ![]() ![]() Attorney’s Office in Maine told The Associated Press. It was the largest Medicare fraud settlement in state history, the U.S. Her complaint was unsealed in federal court Monday, where the terms of the settlement also were filed. ![]() Of that total, $3.8 million will be paid to Alicia Wilbur, a former manager at Martin’s Point from mid-2016 through late 2017 who filed the complaint against the company in June 2018. ![]()
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