"United States ex rel. Scott v. Humana Inc." is a legal case
that involves allegations of fraud against Humana Inc., a health insurance
company.
Case Background:
Plaintiff: The
case was brought by a whistleblower (also known as a "relator"),
named Scott, under the False Claims Act (FCA), which allows private individuals
to sue on behalf of the government if they believe a company is defrauding
federal programs.
Defendant: Humana
Inc., a major health insurance provider.
Allegations:
The whistleblower, Scott, alleged that Humana was involved in fraudulent
activities related to its administration of Medicare Advantage programs.
The Medicare Advantage program, through which private insurers like
Humana provide Medicare benefits, pays insurers more for patients who are
diagnosed with more severe health conditions. The lawsuit claimed that Humana
systematically submitted exaggerated or false diagnosis codes to the Centers
for Medicare & Medicaid Services (CMS). By doing this, Humana allegedly
received higher payments than it was entitled to, thereby defrauding the
government.
Specifically, the accusations centered around upcoding and
misrepresenting patient diagnoses to receive higher payments from Medicare, a
federal program that provides health insurance to individuals aged 65 and
older.
Upcoding involves submitting claims to Medicare that reflect more severe
conditions than the patient has, which leads to higher reimbursement rates.
Scott’s suit was filed in 2016 in the US District Court for the Central
District of California under the case number 16-cv-401 and continued until
August 2024.
Settlement: Humana
agreed to settle the case by paying $90 million to the federal government.
Humana said, "While we are confident in our position and expected
to prevail at trial, we have decided to enter into a settlement agreement
without admitting any wrongdoing to avoid the uncertainty, distraction,
inconvenience, and expense of a lengthy jury trial," in a statement.
Sources:
Case United
States ex rel. Scott v. Humana Inc. (16-cv-401)
https://www.phillipsandcohen.com/humana-settles-for-90-million/
