Bass, Berry & Sims attorney Lindsey Fetzer was interviewed for an article published by Radar on Medicare Advantage examining recent False Claims Act (FCA) settlements with Medicare Advantage (MA) organizations and the Department of Justice (DOJ) that demonstrate a continued scrutiny on MA insurers related to allegations of healthcare fraud.

When asked about trends involving these recent settlements, Lindsey said, “what we see most is the risk adjustment data being submitted [by the plans] to CMS has been fraudulently inflated such that the reimbursement received back is too high. That’s been the consistent refrain … More recently, you’ve seen third parties being involved in sort of the downline of liability, and often those third parties are software type entities, which I think is really interesting when you consider [the growing use of] AI [artificial intelligence].”

Speaking more about AI use in healthcare, Lindsey responded, “health care wants to use AI. They want to do it in a way that can drive patient outcomes. So I think a good example of that would be AI tools that can be used to diagnose diseases in a way that humans might not be able to do [and balancing] the need and desire to use [AI] with this idea that the regulatory instrument is so nascent.”

The full article, “False Claims Act Suits Offer Lessons Learned for MA Plans, Lawyer Says,” was published by AIS Health’s Radar on Medicare Advantage on March 21 and is available online (subscription required).