Case Study

Medicare Risk Adjustment Internal Investigations and Qui Tam Litigation

BRG has worked with outside counsel and health plan clients on several matters involving Medicare Risk Adjustment data and payments. Our experts understand the intricacies of the HCC risk adjustment model, as well as the importance to health plans and capitated providers of accurate coding for appropriate reimbursement and the risks of allegations of non-compliance or fraudulent coding.

BRG experts recently worked with outside counsel to conduct a multifaceted internal investigation of a national health insurer that offers Medicare Advantage plans to eligible populations. BRG worked with the insurer’s Medicare Data Validation unit to develop and execute a sampling plan for an audit of a large, capitated physician group that was alleged to have created false encounters for Medicare members to increase or sustain Medicare risk scores and risk-adjusted capitation amounts. BRG developed the audit plan, compiled the audit results, developed and applied quality control testing to the results, assisted the insurer with quantifying the economic impact of the deletion of encounters that were not supported by the physician group’s medical records, and participated in the insurer’s self-disclosure and negotiations with the government.

BRG Experts

Related Professionals

Tri MacDonald

Principal Executive Officer & President

Washington, DC

Julie Nielsen

Managing Director


Aaron Vandervelde

Managing Director

Washington, DC