Federal Judge Orders Deposition in Elevance Health Medicare Fraud Case
A federal judge has ruled in favor of the Department of Justice to depose a former senior executive of Elevance Health concerning allegations of fraudulent Medicare Advantage claims. On May 20, the judge ordered Peter Haytaian, a previous leader of Elevance's government business and Carelon division, to participate in a 3.5-hour sworn interview. The court dismissed Elevance’s attempts to limit questioning topics, implying that the interview's duration would require the government to focus its inquiries.
This legal development is part of an ongoing lawsuit where the government accuses Elevance, formerly known as Anthem, of violating the False Claims Act. The allegations suggest the insurer deliberately retained incorrect diagnosis codes in Medicare Advantage submissions to the Centers for Medicare & Medicaid Services (CMS). This reportedly enhanced payments through retrospective chart review programs, generating over $100 million annually in certain periods. The case, initially filed in 2020, has persisted through a failed dismissal bid by Elevance in 2022 and remains in the discovery phase.
Involvement and Impact on Business Strategy
The Justice Department argues that Mr. Haytaian played a crucial role in Anthem's chart review practices, holding significant insights into strategic decisions impacting Medicare Advantage operations. The focus is on his involvement in personnel decisions, provider sanctions, and communications with Anthem's board. These elements are suggestive of a "revenue-focused culture" within the company.
Despite the legal proceedings, Elevance has not yet responded to this ruling and previously sought to prevent the deposition. Elevance argued Mr. Haytaian's position as a senior executive qualified him as an "apex witness," potentially exempt from this requirement. Mr. Haytaian has refuted allegations of direct involvement, emphasizing his role was supervisory rather than operational concerning chart review processes.
Role and Regulatory Compliance Issues
From June 2014 to March 2018, Haytaian managed the government business unit, including the disputed Medicare Advantage operations from 2012 to 2015. Post-March 2018, his positions did not involve direct oversight. Before retiring on May 4, he served as president of the Carelon division. Elevance announced his departure in February, attributing it to family priorities, with Haytaian set to remain a special advisor to CEO Gail Boudreaux until 2026. The government initiated his deposition request on February 24, shortly before his announced exit.
The judge's order also resolved discovery disputes, mandating Elevance to produce financial forecast documents from 2012 to 2018, and records concerning compensation and incentives for 27 employees related to risk adjustment and chart reviews. Some board minutes redactions are permitted. The court rejected the government's effort to broaden custodian document access and denied Elevance’s appeal for extra CMS audit records.
In parallel, Elevance is managing a conflict with CMS over Medicare Advantage risk adjustment data submissions. In April, the company revealed a $935 million reserve to address possible enrollment suspension in select plans due to alleged regulatory noncompliance. Elevance has described this issue as a historical payment dispute, not representative of its current operations.