A former executive of Elevance-owned HealthSun Health Plans has been charged for allegedly orchestrating a multimillion-dollar Medicare fraud scheme.
Kenia Valle Boza, 39, was the former director of Medicare Risk Adjust Analytics for the Miami-based organization that operates Medicare Advantage plans in South Florida, according to an Oct. 26 Justice Department news release. She is accused of orchestrating a scheme to submit false and fraudulent information to CMS to increase the amount that HealthSun received for certain Medicare Advantage enrollees.
She and others are accused of entering — and causing 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, according to the release. Ms. Boza and others also allegedly obtained the login credentials assigned to certain physicians to wrongfully access electronic medical records and fraudulently enter chronic conditions directly into the medical records of beneficiaries. The conditions were entered into beneficiaries' medical records often days or weeks after the physician saw the patient.
The scheme allegedly caused HealthSun to submit tens of thousands of false claims to CMS, which resulted in millions of dollars in overpayment.
Ms. Boza is charged with one count of conspiracy to commit healthcare fraud and wire fraud, two counts of wire fraud and three counts of major fraud against the U.S.
The Justice Department, meanwhile, has declined prosecution of HealthSun because of the organization's voluntary self-disclosure and agreement to repay $53 million in overpayments, the release said. HealthSun was acquired by Elevance Health in 2017.
HealthSun provides Medicare Advantage and Part D plans to more than 50,000 members in Dade, Broward and Palm Beach counties. The company also has a Medicaid managed care contract with the state of Florida, according to its website.