Former Executive at Medicare Advantage Organization Charged for Multimillion-Dollar Medicare Fraud Scheme

The Justice Department today announced charges against a former executive at HealthSun Health Plans Inc. (HealthSun), 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. CMS pays Medicare Advantage plans like those HealthSun operates based, in part, on the health condition of their 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-health care providers, such as coders, added to patient health records.

For example, Valle and her co-conspirators allegedly entered and caused others to enter diagnoses into the medical records of beneficiaries enrolled in HealthSun’s plans based on diagnostic tests that were not a proper basis for diagnosing those conditions. In addition, Valle and her co-conspirators allegedly obtained the login credentials assigned to certain physicians to wrongfully access electronic medical records (EMR) as the physicians, and falsely and fraudulently entered chronic conditions directly into the medical records of beneficiaries. These diagnoses appeared to have been made and documented by the physicians when, in truth and fact, coders entered the conditions into beneficiaries’ medical records, often days or weeks after the physician saw the beneficiary. As a result of the scheme, Valle and her co-conspirators allegedly caused HealthSun to submit to CMS tens of thousands of false and fraudulent diagnosis codes, which resulted in CMS overpaying HealthSun millions of dollars.

Valle is 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 against the United States. If convicted, Valle faces a maximum penalty of 20 years in prison on the conspiracy count and on each wire fraud count, and a maximum penalty of 10 years in prison on each count of major fraud against the United States.

Acting Senior Counselor Brent Wible of the Justice Department’s Criminal Division, Deputy Inspector General for Investigations Christian J. Schrank of the Department of Health and Human Services Office of Inspector General (HHS-OIG), and Assistant Director Luis Quesada of the FBI’s Criminal Investigative Division made the announcement.

HHS-OIG and the FBI Miami Field Office are investigating the case.

Assistant Chief John “Fritz” Scanlon and Trial Attorney Alexander Thor Pogozelski of the Criminal Division’s Fraud Section are prosecuting the case.

An indictment is merely an allegation. All defendants are presumed innocent until proven guilty beyond a reasonable doubt in a court of law.