Why did Sutter Health and affiliates violated the False Claim Act and agreed to pay $90 million to resolve the allegations? Under the False Claim Act, claim for services not supported by the patient's medical record were claimed. Sutter Health violated the False Claim Act by knowingly submitting "unsupported diagnosis codes for certain patient encounters for beneficiaries under its care" (Justice News). Even if the provider makes innocent billing mistakes, the provider has the duty repay the government. But Sutter Health deliberately ignored the inaccuracies because "once Sutter Health became aware of these unsupported diagnosis codes, it failed to take sufficient corrective action to identify and delete additional unsupported diagnosis codes" (Justice News, 2021). It is the duty of the providers to ensure that the claims they submitted to Medicaid and Medicare are accurate (OIG, 2021). However, in this case, Sutter Health ignored the inaccuracies and deliberately submitted the false claims.

The Corporate Integrity Agreement (CIA) requires that "Sutter Health implement a centralized risk assessment program as part of its compliance program and hire an Independent Review Organization to annually review a sample of Sutter Health's Medicare Advantage patients' medical records and associated diagnoses data" (Justice News, 2021) why was this implemented?

Implementation of the compliance program will not be effective since in the past they intentionally ignored the inaccurate claims. Which means Sutter Health already had a compliance program since they were able to decipher the unsupported diagnosis codes but failed to take corrective action. Education and training must be given to all levels of employees, and all must understand the importance of compliance. Through education, the organization must understand the harmful effect of submitting false claims and learn to foster compliance. Though, I think the requirement to hire an Independent Review Organization will help to ensure that the Sutter Health does not submit false claims in the future because then the independent reviewer "can file an action on behalf of the United States and receive a portion of any recovery" (Justice News, 2021). A robust audit and review program can help to identify billing mistakes, so by hiring an independent reviewer, the government does not have to worry about Sutter Health making deliberate false claims again in the future thus abiding by CIA requirements (OIG, 2021).

https://www.justice.gov/opa/pr/sutter-health-and-affiliates-pay-90-million-settle-false-claims-act-allegations-mischarging

https://oig.hhs.gov/newsroom/video/2011/heat_modules.asp