Continuing its recent slate of high-profile indictments, convictions, and plea agreements involving healthcare executives who have violated federal healthcare laws, the US Department of Justice (DOJ) recently announced charges against a healthcare executive for her role in a Medicare fraud scheme.

Kenia Boza, the former director of Medicare risk adjustment analytics at a Medicare Advantage organization in South Florida, allegedly submitted false and fraudulent information to the Centers for Medicare & Medicaid Services (CMS) to increase the amount of money recovered for Medicare Advantage enrollees.

Ms. Boza, along with co-conspirators, allegedly entered diagnoses into medical records of beneficiaries based on diagnostic tests that were not proper for diagnosing those specific medical conditions. Additionally, the DOJ alleged they entered ailments that the beneficiaries “did not actually have, and that non-healthcare providers, such as coders, added to patient health records.”

While the diagnoses looked like they were made and entered by physicians, “in truth and fact, coders entered the conditions into beneficiaries’ medical records, often days or weeks after the physician saw the beneficiary.” Ultimately, Ms. Boza and her co-conspirators allegedly submitted tens of thousands of false diagnosis codes, resulting in the overpayment of millions of dollars, according to the indictment.

In a 17-page indictment, the DOJ explained that Ms. Boza allegedly supervised and directed the activities of the coders who illegally entered false encounter information that was submitted to CMS. Additionally, she entered the false encounter information herself. Ms. Boza and others would enter diagnoses of “Other Hemoglobinopathies and Disorder of Carbohydrate Metabolism, Unspecified” based on elevated HbA1c test results, all while knowing that elevated HbA1c test results were not a proper means of diagnosis for either of those conditions.

Ms. Boza has been charged with conspiracy to commit healthcare fraud and wire fraud (one count), wire fraud (two counts), and major fraud against the United States (three counts). She faces up to 10 years in prison for the conspiracy charge, 20 years’ imprisonment for each wire fraud count, and up to 10 years’ imprisonment for each count of major fraud.

The day after Ms. Boza was indicted, the DOJ declined to charge Ms. Boza’s employer upon application of the factors in the Corporate Enforcement and Voluntary Self-Disclosure Policy in the Justice Manual. The DOJ considered facts including (1) the timeline and voluntary disclosure of the conduct; (2) the entity’s proactive cooperation in the investigation; (3) the nature and seriousness of the offense; (4) timely and appropriate remediation; and (5) the fact that the entity agreed “to immediately remit the amount that CMS overpaid as a result of the criminal scheme.” CMS was repaid approximately $53 million that it overpaid between 2016 and 2021.

This indictment demonstrates that even when a corporation avoids criminal prosecution, individual executives allegedly engaged in criminal misconduct may be prosecuted.