Summary
The United States has announced a $36.5 million settlement with Matrix Medical Network over allegations involving Medicare Advantage payments. Federal authorities alleged that the company reported unsupported medical diagnoses that led to higher payments from Medicare. The settlement resolves claims under the False Claims Act and requires Matrix Medical Network to comply with a five-year Corporate Integrity Agreement.
Matrix Medical Network Settles Medicare Fraud Allegations
The United States has reached a $36.5 million settlement with Matrix Medical Network, a healthcare services company headquartered in Nashville, Tennessee. The company performs in-home health assessments for patients enrolled in Medicare Advantage plans.
According to the government, Matrix Medical Network caused Medicare Advantage Organizations (MAOs) to submit false or invalid diagnosis information to the federal government. These diagnoses were allegedly used to increase risk scores for patients, which resulted in higher Medicare payments to insurance plans.
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The allegations focus on activities that took place between 2014 and 2019. During that period, Matrix Medical Network conducted in-home assessments and reported diagnosis codes that were later submitted to the Centers for Medicare and Medicaid Services (CMS).
Federal authorities claimed that some of these diagnoses were not adequately supported by clinical information and did not meet required coding standards.
Among the medical conditions cited in the allegations were atrial fibrillation, rheumatoid arthritis, chronic obstructive pulmonary disease (COPD), simple chronic bronchitis, proliferative diabetic retinopathy, drug-induced polyneuropathy, and rheumatoid polyneuropathy.
The government alleged that many of these diagnoses were not confirmed by other healthcare providers who treated the same patients during surrounding years. As a result, Medicare Advantage plans allegedly received inflated reimbursement payments from CMS.
The settlement was approved by U.S. District Judge Andrew L. Carter.
How the Alleged Scheme Worked and Settlement Requirements
Medicare Advantage, also known as Medicare Part C, allows private insurers to provide Medicare coverage. Payments to these insurers are adjusted based on the health conditions of enrolled members. Patients with more serious conditions generally generate higher payments because they are expected to require more healthcare services.
According to the complaint, Matrix Medical Network marketed its services to MAOs by highlighting its ability to identify additional diagnoses that could increase patient risk scores and reimbursement payments.
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The company’s assessments were typically performed by nurse practitioners who collected medical histories, reviewed medications, and completed electronic health assessment forms. These visits did not involve providing treatment or prescribing medication.
Federal authorities alleged that Matrix’s coding and review teams later examined assessment records to identify additional diagnoses for reporting purposes. In some cases, the government claimed that diagnoses were reported even when the assessment forms lacked sufficient clinical information to support them.
The government also alleged that Matrix reported thousands of unsupported diagnoses that ultimately led to millions of dollars in additional Medicare payments.
As part of the settlement, Matrix Medical Network admitted that in numerous instances its assessment forms did not contain enough clinical information to support certain diagnoses reported to MAOs. Those diagnoses were frequently submitted to CMS and often resulted in higher Medicare reimbursements.
In addition to paying $36.5 million, Matrix entered into a five-year Corporate Integrity Agreement with the Department of Health and Human Services Office of Inspector General (HHS-OIG).
The agreement requires:
- Annual risk assessments
- Ongoing compliance monitoring
- Independent compliance reviews
- Audits of risk adjustment activities
- Reviews of services provided to Medicare Advantage beneficiaries
The government also noted that the lawsuit involved a whistleblower action filed under the False Claims Act.
In a separate settlement announced on the same day, HealthFair, a company acquired by Matrix in 2018, and its former owner, Shahriah “James” Ekbatani, agreed to resolve separate allegations involving unsupported diagnoses generated through mobile health assessment programs.