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A former executive of Florida health insurance company HealthSun Health Plans Inc, which offers privately managed but publicly funded Medicare Advantage plans, has been charged with orchestrating a scheme that resulted in the federal government being overbilled by $53 million, prosecutors announced Thursday.

According to an indictment filed, opens new tab in Miami federal court, Kenia Valle Boza, who served as Director of Medicare Risk Adjustment Analytics at HealthSun from 2017 to 2020, fraudulently told the federal government that beneficiaries of HealthSun Medicare Advantage plans had chronic conditions that they did not really have.

That allegedly allowed the company to receive larger reimbursements from the U.S. Centers for Medicare and Medicaid Services (CMS).

Prosecutors said they did not charge HealthSun itself, thanks to its cooperation in the case and agreement to return $53 million in overpayments to CMS.

A lawyer for Valle did not immediately respond to a request for comment.

In a Medicare Advantage plan, insurers are paid a fixed amount per patient, which depends in part on the patients' medical conditions. Certain diagnoses result in higher payments.

Prosecutors said that, in order to carry out their scheme, Valle and unnamed co-conspirators obtained physicians' login credentials to add fake diagnoses to patients' electronic medical records.

The scheme allegedly caused HealthSun to submit tens of thousands of false diagnoses to CMS.

The indictment charges Valle with conspiracy and wire fraud. The most serious charges carry a maximum sentence of 20 years in prison.

Medicare Advantage, created in 1997, was touted as a way of bringing down Medicare costs by encouraging private companies to innovate. However, critics say it has instead created incentives for fraud, and multiple insurance companies have been sued by the government for allegedly falsifying claims in order to get higher reimbursements.

The case is USA v. Valle Boza, U.S. District Court for the Southern District of Florida, No. 1:23-cr-20417.