Bond v. Clover Health Investments, Corp.

CourtDistrict Court, M.D. Tennessee
DecidedFebruary 14, 2023
Docket3:21-cv-00096
StatusUnknown

This text of Bond v. Clover Health Investments, Corp. (Bond v. Clover Health Investments, Corp.) is published on Counsel Stack Legal Research, covering District Court, M.D. Tennessee primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Bond v. Clover Health Investments, Corp., (M.D. Tenn. 2023).

Opinion

UNITED STATES DISTRICT COURT MIDDLE DISTRICT OF TENNESSEE NASHVILLE DIVISION

TIMOTHY BOND, ) ) Lead Plaintiff ) ) and ) Case No. 3:21-cv-00096 ) Judge Aleta A. Trauger JEAN-NICOLAS TREMBLAY, ) ) Named Plaintiff, ) ) Individually and on behalf of all others ) similarly situated, ) ) v. ) ) CLOVER HEALTH INVESTMENTS, ) CORP. f/k/a SOCIAL CAPITAL ) HEDOSOPHIA HOLDINGS CORP. III, ) VIVEK GARIPALLI, ANDREW TOY, ) JOE WAGNER, and CHAMATH ) PALIHAPITIYA, ) ) Defendants. )

MEMORANDUM

Firas Jabri and Jean-Nicholas Tremblay have filed a Motion for Class Certification (Doc. No. 101), to which defendants Clover Health Investments, Corp. f/k/a Social Capital Hedosophia Holdings Corp. III (“SCH”), Vivek Garipalli, Andrew Toy, Joe Wagner, and Chamath Palihapitiya have filed a Response (Doc. No. 108), and Jabri and Tremblay have filed a Reply (Doc. No. 110). For the reasons set out herein, the motion will be granted. I. BACKGROUND A. Medicare Advantage and the Problem of Risk Adjustment Fraud In 1997, “Congress created ‘Medicare Part C,’ sometimes referred to as Medicare Advantage [‘MA’]. Under Part C, beneficiaries may choose to have the government pay their

private insurance premiums rather than pay for their hospital care directly.” Azar v. Allina Health Servs., 139 S. Ct. 1804, 1809 (2019). The federal government funds MA plans on a “capitated” basis, meaning that the private company operating a plan “receive[s] in advance a monthly lump sum from CMS for every beneficiary that [it] enroll[s], without regard to the services that the beneficiaries will actually receive.” UnitedHealthcare Ins. Co. v. Becerra, 16 F.4th 867, 873 (D.C. Cir. 2021). The capitated monthly rate for each patient, however, is not necessarily the same. The Center for Medicare and Medicaid Services (“CMS”) “uses a model—called the CMS Hierarchical Condition Category, or CMS-HCC, risk-adjustment model”—that assigns each Part C beneficiary a “risk assessment score” based on a formula considering various “demographic characteristics” that are “predictive of differing costs of care.” Id. at 874 (citing 42 U.S.C. §

1395w-23(a)(1)(C)(i)). CMS’s formula allows the agency to “determine prospectively, based on Medicare Advantage beneficiaries’ actuarially relevant, known demographic and health characteristics, the per-capita payment rate that will fairly compensate th[e] Medicare Advantage insurer” for providing the beneficiary’s coverage for that month. Id. at 873. If capitation rates were based solely on general, verifiable demographic traits such as age and sex, CMS’s job in setting the scores would be as simple as consulting its own enrollment data and applying a formula to the numbers it found. In order for the risk assessment formula to be as effective as possible, however, Congress has authorized CMS to consider any “such other factors as the Secretary determines to be appropriate, including adjustment for health status.” 42

U.S.C. § 1395w-23(a)(1)(C)(1). The result is a somewhat more complex model that relies, among other things, on data provided by beneficiaries’ healthcare providers, including with regard to “individuals’ medical diagnoses.” U.S. ex rel. Anita Silingo v. WellPoint, Inc., 904 F.3d 667, 672 (9th Cir. 2018) (citing Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs, 74 Fed. Reg. 54,634, 54,673 (Oct. 22, 2009)).

While this additional data allows risk assessment scores to be more precise, it also introduces a vulnerability into the system. “With data for millions of people being submitted each year, CMS is unable to confirm diagnoses before calculating capitation rates.” Id. As a result, capitated rates may be skewed upward or downward based on providers’ misreporting (or non-reporting) of patient information. In order to mitigate that problem, “Medicare regulations require risk adjustment data to be produced according to certain best practices.” Id. (citing Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs, 79 Fed. Reg. 1918, 2001 (Jan. 10, 2014)). While those regulations may have had some success in combating data reporting errors— particularly inadvertent ones—they have not been able to wholly eradicate the practice of

intentional overreporting of risk factors or, as it has come to be known, “risk adjustment fraud.” Because risk factors are reported by healthcare providers, but the inflation of a patient’s risk score benefits only the insurer, there is no inherent incentive to commit the fraud—at least as long as those parties are kept at an arm’s length from each other. However, if a Part C plan operator can find a way to induce, encourage, or trick healthcare providers into over-reporting a beneficiary’s risk factors without actually implementing a more expensive course of treatment, the insurer can receive a higher capitated payment for that beneficiary without actually having to pay for more services. B. Clover and the Clover Assistant Garipalli founded the original Clover1 in 2013 for the purpose of providing Medicare Advantage plans. (Id. ¶ 56.) Historically, the Part C/MA market has been concentrated among a handful of large insurers with patient bases far larger than Clover’s. Clover has publicly acknowledged its comparatively weak market position, but the company and its executives

characterized the MA field as, in the words of one press release, “ripe for disruption” after having “seen little innovation” for years. (Doc. No. 70 ¶ 61.2) According to that press release, Clover was designed to provide that disruption with its “unique model,” through which it “partner[ed] with primary care physicians using its software platform, the Clover Assistant, to deliver data-driven, personalized insights at the point of care.” (Id. ¶ 63.) Clover described the Clover Assistant as its “flagship software platform . . . to provide America’s seniors with PPO and HMO plans that are the obvious choice for Medicare-eligible consumers.” (Id. ¶ 66.) According to Clover, the Assistant used “machine learning” to analyze “millions” of data points in order to provide “actionable and personalized insights at the point of care.” (Id. ¶ 66.) The plaintiffs, however, claim that the purpose of the Clover Assistant was far

simpler: it was “designed to identify opportunities to assign higher Medicare risk adjustments so that Clover [could] obtain larger reimbursements from Medicare.” (Id. ¶ 67.) It did this by, among other things, guiding physicians’ offices to record information that, based on the Medicare risk assessment formula, were likely to result in upward revisions of the patient’s risk assessment score. Those upward revisions made Clover’s deals with Medicare more profitable

1 For the sake of concision, the court will use the name “Clover” broadly to refer to both SCH and so- called “Legacy Clover,” which the court is describing here. Although the distinction between the entities is an important fact in the context of the case as a whole, that level of precision is mostly unnecessary in connection with the current motion.

2 Although the assertions in the First Amended Complaint were, at the time of filing, mere allegations, the defendants have admitted many of the underlying details in their Answer. (See Doc. No. 94.) The court accordingly will cite to the First Amended Complaint for certain now-admitted background facts—such as quotes from publicly available documents—relevant to the current motion, as well as to summarize aspects of the plaintiffs’ theory of the case. by allowing Clover to receive higher capitated payments for individual patients. (Id. ¶¶ 57, 67– 69.) While there is nothing inherently wrong with encouraging physicians to report information likely to result in higher risk assessment scores, doing so through improper means or

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Hansberry v. Lee
311 U.S. 32 (Supreme Court, 1940)
Affiliated Ute Citizens of Utah v. United States
406 U.S. 128 (Supreme Court, 1972)
Eisen v. Carlisle & Jacquelin
417 U.S. 156 (Supreme Court, 1974)
Califano v. Yamasaki
442 U.S. 682 (Supreme Court, 1979)
General Telephone Co. of Southwest v. Falcon
457 U.S. 147 (Supreme Court, 1982)
Basic Inc. v. Levinson
485 U.S. 224 (Supreme Court, 1988)
Wal-Mart Stores, Inc. v. Dukes
131 S. Ct. 2541 (Supreme Court, 2011)
Dorothy Weathers v. Peters Realty Corporation
499 F.2d 1197 (Sixth Circuit, 1974)
Gooch v. Life Investors Insurance Co. of America
672 F.3d 402 (Sixth Circuit, 2012)
In Re American Medical Systems, Inc. Pfizer, Inc.
75 F.3d 1069 (Sixth Circuit, 1996)
Lloyd D. Alkire v. Judge Jane Irving
330 F.3d 802 (Sixth Circuit, 2003)
Comcast Corp. v. Behrend
133 S. Ct. 1426 (Supreme Court, 2013)
Gina Glazer v. Whirlpool Corporation
722 F.3d 838 (Sixth Circuit, 2013)
Cammer v. Bloom
711 F. Supp. 1264 (D. New Jersey, 1989)
Glickenhaus & Company v. Household International, Inc.
787 F.3d 408 (Seventh Circuit, 2015)

Cite This Page — Counsel Stack

Bluebook (online)
Bond v. Clover Health Investments, Corp., Counsel Stack Legal Research, https://law.counselstack.com/opinion/bond-v-clover-health-investments-corp-tnmd-2023.