Zoom Health Plan is under investigation by the FBI for allegedly falsifying medical claims to avoid paying about $3 million to the Affordable Care Act, according to a report by the
Portland Business Journal.
Citing a former employee who spoke on the condition of anonymity, the
Business Journal reported that Zoom is alleged to have retroactively falsified claims after learning it would have to pay into the ACA’s risk adjustment program because it hadn’t spent a high enough proportion of its revenue on medical claims.
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Insurance companies that sell plans on the health exchange are required to spend at least 80% of their premium revenue on medical services or pay into the ACA’s risk adjustment program. But Zoom’s “medical loss” ratio was only around 30%, according to the
Business Journal. To make up the difference, Zoom is alleged to have retroactively altered claims paid to sister company ZoomCare to make them look higher than they actually were.
Zoom spokesman Len Bergstein confirmed that the FBI had interviewed some of the company’s staff members last week. The interviews were about the “calculation of risk adjustment,” Bergstein told the
Business Journal.
Bergstein also said that investigators had issued a subpoena for information or files from Zoom, although no subpoenas were issued to individual staff members or executives. He wouldn’t comment further on the issue.
“Your readers should not believe everything they read, especially when it is an anonymous quote by some person not under oath,” he told the
Business Journal.
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