‫‪Case 7:17-cv-07515-KMK Document 12 Filed 08/04/20 Page 1 of 64‬‬ ‫‪. :‬ﻩ ‪ ٥٨٨‬ﺃﺍﺀ ‪ ٩‬ﺍﺃﺍﺃﺀ‬ ‫ﺀﺍﺃﺩﻻ´´ ﺀ‪٦‬ﺍ( ﺀﺍ(ﻻﺀ ‪،( ٩ .‬ﺀ~ﻩ‪(.8‬ﺀ‪«.٠‬ﺀ ﻩﺀﺃ‪ ٠‬ﺀ‪( ٩٠-‬ﻩ ﺩﺀ(ﻩ(‪ 5‬ﺃﺀ(‪:‬ﺀﺗﺎ ﺀ‪(. (١‬ﺀ‪:‬ﺩﺍﻡ‪،-‬ﻩﺀ ﺩ(‪ ٠:‬ﻩ ﺀ‬ ‫‪:‬ﺩﻻﻫﺎﺍﻩ‪ ٤‬ﺩﺩ ﺩﺀﻭﺀ‪ 1‬ﺍﺩ‪´´).‬ﺩﺀ(ﻩﺀ‪5‬‬ ‫‪، ٠٠‬ﺩ( ﺀﺀ‪ ٠:‬ﻡ‪<5‬ﺍ(ﺍﺩﺀ‪. (´´)1‬ﺀ‪ ٠‬ﺍ‬ ‫ﺍ(ﺍﺩﺀ)( ‪ 1:(٠8‬ﺀﺩ‪(٦5( ٠:‬ﺍﺩﺀ)ﺃ‪´).‬ﺃﺍ‪٠‬ﺀ‪ ٩٠‬ﻩﺀ ‪ (´´٨‬ﺀ‪( 11‬ﺩ‪ ٩ <٠‬ﻩﺀﻑ‪«‌´´).‬‬ ‫ﺩ‪ ٨‬ﺩﺃ‪،‬ﺃﺩﻩ‪ ٩٢‬ﺀﻩ‪،‬ﻩ ‪ ٨‬ﻁ ﺀﻩ‪(´`).‬ﺩﺀﻣﺎﺭ ﺍﻻ~`´( ‪( (.٩‬ﺩﺀﻣﺎﻭ (ﺍﻣﺎ~‪1٧١´´).‬ﻷ´`(‪.‬ﻣﻪ‪. 1٨‬ﻻ‪، ٦‬ﺩﻩ‪.‬ﻩ ﺀ ﺀﺀ‪٨‬ﺩ‪،‬ﻣﺎﺩ‪1٨‬‬ Case Document 12 Filed 08/04/20 Page 2 of 64 2. This action is being brought as a result of false and fraudulent risk adjustment claims that were submitted to The Centers for Medicare Medicaid Services by between 2012 and 2017 using improper diagnostic codes under the International Classi?cation of Diseases, Clinical Modi?cation system Codes?). These 1CD Codes referred to health conditions of Medicare beneficiaries that did not exist, (2) were not recorded in any medical records and (3) were not based on clinically reliable information. intentionally mispresented these health conditions as part of a widespread scheme to coax CMS into paying a higher capitated rate on behalf of Medicare bene?ciaries enrolled in Medicare Advantage plans (the Plans?). CMS, unaware that these claims were false and fraudulent and relying on the faulty 1CD codes, overpaid by more than $1.4 billion. PARTIES 3. Defendant Cigna is a Delaware corporation with its principal place of business located at 900 Cottage Grove Rd, Bloom?eld, Connecticut. Ci gna through its subsidiaries is one of the largest health services organizations in the United States. Based on its 2016 Annual Report filed with the US Securities and Exchange Commission, in 2016 Cigna earned approximately $39.7 billion in total revenue and it had approximately $56.4 billion in assets at December 31, 2016. 4. Defendant Ci gna Holdings is a Delaware corporation and wholly?owned subsidiary of Cigna with its principal place of business located at 900 Cottage Grove Rd, Bloom?eld, Connecticut. On information and belief Cigna Holdings is a holding company that through its direct and indirect wholly?owned subsidiaries owns and controls all of Cigna?s assets in the United States. Case Document 12 Filed 08/04/20 Page 3 of 64 5. Defendant CGC is a Connecticut corporation and whollywowned subsidiary of Cigna Holdings with its principal place of business located at 900 Cottage Grove Rd, Bloom?eld, Connecticut. On information and belief, CGC is a holding company of numerous direct and indirect wholly-owned subsidiaries that engage in a range of insurance and insurance?related businesses within the United States. 6. Defendant Parent is a Delaware corporation and wholly-owned subsidiary of CGC with its principal place of business located at 9009 Carothers Pkwy, Building B, Suite 501, Franklin, Tennessee 37067. On information and belief, Parent is the parent company of all of the entities that collectively comprise the business known as The business has been a part of the CGC ownership structure since 2012 when it was acquired by CGC for $3.8 billion. 7. Defendant New Quest is a Texas corporation and wholly-owned subsidiary of Parent with its principal place of business located at 44 Vantage Way, Suite 300, Nashville, Tennessee. On information and belief New Quest is the owner and manager of several direct and indirect wholly?owned subsidiaries that operate Medicare Advantage plans Plans?) and health maintenance organizations Within the United States, and engage in other insurance-related businesses. The Medicare Advantage plans operated by New Quest?s subsidiaries provide health insurance to more than 300,000 Medicare beneficiaries nationwide. 8. Defendant HLHI is a Texas corporation and wholly?owned subsidiary of New Quest with its principal place of business located at 2900 North Loop W, Suite 1300, Houston Texas. Insurance operates the MA Plans which provide health insurance coverage to Medicare beneficiaries in 13 states nationwide. Case Document 12 Filed 08/04/20 Page 4 of 64 9. Defendant Alegis is an Illinois limited liability company and wholly?owned subsidiary of New Quest with its principal place of business located at 1340 South Darnen Avenue, Suite 210, Chicago, Illinois. Alegis provides healthcare services to Medicare bene?ciaries enrolled in the MA Plans, including chronic care management services and health assessments. 10. Defendant Gulf Quest is a Texas limited partnership and subsidiary of New Quest with its principal place of business located at 2900 North Loop W, Suite 1300, Houston, Texas. On information and belief Gulf Quest provides management services to HLHI. 11. Relator is a United States citizen residing in the State of Connecticut and an of?cer of Texas Health Management LLC a Texas limited liability company. THM was a service provider of between 2012 and 2017. Relator?s knowledge of the matters giving rise to this action stem from his position as an of?cer and bene?cial owner of equity in THM. 12. The United States, on whose behalf Relator brings this action, is the real party in interest with respect to the claims asserted herein. The United States through its agency CMS has ongoing contracts with as a Medicare Advantage Organization that participates in the Medicare and Medicaid programs. JURISDICTION AND VENUE 13. This Court has jurisdiction over the subject matter of this action pursuant to 28 U.S.C. 1331 and 31 U.S.C. 3732, the latter of which speci?cally confers jurisdiction on this Court for actions brought pursuant to 31 U.S.C 3729 and 3730. 14. There have been no public disclosures of the allegations or transactions contained herein that bar jurisdiction under 31 U.S.C 3730(e). Case Document 12 Filed 08/04/20 Page 5 of 64 15. This Court has personal jurisdiction over Defendants pursuant to 31 U.S.C 3732(a) because that section authorizes nationwide service of process and because Defendants have at least minimum contacts with the United States, and can be found in, reside, or transact or have transacted, business in the Southern District of New York. 16. Venue exists in the United States District Court for the Southern District of New York pursuant to 31 U.S.C 3732(a) and 3730(b)(1) because all of the Defendants have at least minimum contacts with the United States, and one or more of the Defendants can be found in, reside, or transact or have transacted business in the Southern District of New York. Among other things, (1) maintains the following of?ces within the Southern District of New York: (A) 50 Main Street, 9th Floor, White Plains, New York, (B) 140 E. 45th Street, New York, New York and (C) 14 Wall Street, New York, New York, (2) markets and sells health insurance products within Westchester and New York counties within the State of New York, including Medicare plans such as the Rx Secure Plan and the Rx Secure~Extra Plan, (3) network providers operate businesses within Westchester and New York Counties within the State of New York, (4) is an approved provider of Medicare Advantage plans to New York City former employee retirees and these plans are advertised on the New York City government web site and (5) is a publicly?traded company whose common stock is traded on the New York Stock Exchange. BACKGROUND The Medicare Advantage Program 17. CMS administers a program known as ?Medicare,? which provides health insurance coverage to several types of individuals, including those who are (1) at least 65 years Case Document 12 Filed 08/04/20 Page 6 of 64 of age, (2) under age 65 with certain disabilities and (3) of any age with End-Stage Renal Disease. 18. The bene?ts afforded by the Medicare program are divided into four segments: (1) Medicare Part A, which covers certain medically necessary services, such as inpatient hospital stays, care in skilled nursing facilities, hospice care and certain home health care, (2) Medicare Part B, which covers certain preventative care, such as outpatient care, medical supplies and services necessary to treat or prevent a medical condition, clinical research and ambulance services, (3) Medicare Part C, which covers bene?ts for bene?ciaries enrolled in private health insurance plans, including all of the bene?ts of Medicare Parts A and B, and (4) Medicare Part D, which covers prescription drug costs. 19. Eligible individuals can participate in the Medicare program by enrolling in traditional Medicare, which is managed directly by the federal government, or in a MA Plan established under Medicare Part which is managed by a private health insurer Organization?). Medicare Advantage plans are required to offer the same bene?ts to Medicare bene?ciaries enrolled in the plan (?Plan Members?) as they would be entitled to receive under traditional Medicare. 20. Traditional Medicare and Medicare Advantage plans are both subsidized with funding from the federal government but they pay the bene?ciary?s healthcare costs in different ways. Under traditional Medicare, CMS pays healthcare providers for the services they render on a fee?for?service basis. The fees are determined by rates set forth in a set of fee schedules that CMS updates on an annual basis. Providers submit a claim to CMS for each service they render and CMS pays the provider based on the applicable rate. Case Document 12 Filed 08/04/20 Page 7 of 64 21. Under Medicare Advantage, CMS does not pay healthcare costs directly but rather pays the MA Organization a ?at ?capitated rate? each month and the MA Organization in turn pays the providers for the services they render. MA Organizations are not required to follow the fee?for~service model and generally speaking may structure their payment arrangements with providers as they see 22. The capitated rate that CMS pays to a MA Organization is an amount determined on a per?bene?ciary per-month basis using a ?risk adjustment? model which weighs the relative ?nancial risks of each bene?ciary enrolled in the MA Plan based on his or her health status. This model was designed by CMS in recognition of the fact that the health status of Medicare bene?ciaries vary signi?cantly. Section 2.1 of Evaluation of the CMS-HCC Risk Adjustment Model Final Report, dated March 2011, prepared by RTI International for CMS. CMS reasoned that unless payments were adjusted to take into account the ?nancial risks entailed by enrolling bene?ciaries with the most serious and costly health conditions, MA Organizations would seek to enroll only those bene?ciaries who were in good health and were likely to incur minimal healthcare costs. 1d. The risk adjustment model attempts to compensate MA Organizations for these variations in ?nancial risk. 23. To calculate the pernbene?ciary per?month amount under the risk adjustment model, CMS ?rst assigns a ?risk score? to each Plan Member based on that Plan Member?s relative health status. CMS obtains information concerning each Plan Member?s health status from several sources, most important among them being the MA Organization itself, which reports to CMS health data concerning the Plan Members. The data is required to be reported in the form of ICD Codes that describe the relevant health conditions. The MA Organization Case Document 12 Filed 08/04/20 Page 8 of 64 obtains this data from the Plan Members? healthcare providers who are required to report to the MA Organization diagnoses they render during a patient encounter. 24. CMS organizes the ICD Codes data into separate groups of clinically related health conditions that have similar cost implications. HCCS are each assigned a numerical value. The more serious and costly that a particular HCC is to monitor and treat, the higher the value that will be assigned to that health condition. Chronic health conditions such as diabetes are assigned higher values while generic health conditions are assigned low values or no values at all. 25. These values are added together to arrive at an overall risk score for the Plan Member. This number represents the Plan Member?s ?nancial risk to the MA Plan relative to a hypothetical ?average? bene?ciary within the plan (the ?Average Beneficiary?). For the Average Beneficiary, the overall risk score is 1.0 and CMS assigns a per?bene?ciary per?month base rate each year that would correspond to this risk score (the ?Base Rate?). 26. If a Plan Member has a risk score that is higher or lower than the Average Bene?ciary risk score of 1.0, then the amount associated with that Plan Member will be adjusted upwards or downwards proportionally. For example if a Plan Member?s risk score is 1.2, the amount will be 20% higher than the Base Rate. Conversely if a Plan Member?s risk score is 0.80, the amount will be 20% lower than the Base Rate. 27. Adjustments are made to each bene?ciary?s risk score annually based on the ICD codes submitted to CMS by the MA Organizations. These adjustments are prospective in the sense that 1CD codes for patient encounters in a given year is used to predict the costs and adjust the payment for the following year. Case Document 12 Filed 08/04/20 Page 9 of 64 The 360 Program 28. In 2012 Ci initiated a program known as the ?360 Program.? This program was designed to engage primary care providers in the Ci network to perform a type of health assessment for the Plan Members which Cigna- refers to as a ?3 60.? 29. A 360 is an ?enhanced? version of an annual wellness visit An AWV is a Medicare bene?t which entitles a bene?ciary to an annual face?to-face encounter with a health professional that includes the following services: (1) review (and administration, if needed) of an updated health risk assessment; (2) update to the patient?s medical and family history; (3) update to the list of current providers and suppliers involved in the patient?s medical care; (4) Measurement of patient?s weight (or waist circumference), blood pressure and other routine measurements as deemed appropriate; (5) Detection of cognitive impairment; (6) update to the patient?s written screening checklist and a list of risk factors with intervention and recommendations; (7) furnish personalized health advice and a referral, as appropriate, to health education or preventative counseling services or programs; and (8) Discretionary advance care planning services that may be requested by the patient; 42 CF 410.15. The 360 goes beyond the scope of the AWV in that it also includes a routine physical exam. Case Document 12 Filed 08/04/20 Page 10 of 64 30. Senior executives at pitched the 360 to PCPs as a means for closing ?gaps in care.? They pointed out that these gaps existed because many Plan Members were not visiting their PCPs for an annual physical exam due to the fact that Medicare would not cover the cost. As a result, they claimed that serious health conditions were not being detected and that by performing the 3603 PCPs would be able to diagnose and treat these health conditions and therefore improve the quality of care. 31. Even though pitched the 360 in this manner, quality of care was not the underlying purpose of the 360 Program. The program centered on a business model devised by in which the 360 would be used to ?nd health conditions that could raise the risk scores of the Plan Members and therefore increase the capitated payments that CMS paid to The 360 Form 32. In order to achieve the goal of raising risk scores, senior executives within Cigna? engineered a system of targeting Plan Members who were most likely to have with the highest potential for risk score and revenue increases. working within Ci gna?s af?liate Gulf Quest utilized a data~mining tool known as Predilytics to search the medical histories of all of the Plan Members and then organize the Plan Members into different priority categories. These categories were labeled ?critical,? ?high,? ?moderate,? ?low? and ?very low.? Members with chronic diseases and Plan Members who had never received a 360- exam were assigned the highest priorities. 33. Senior executives at also engineered a system for performing the 360 that would capture as many diagnoses as possible. The principal contributor to the development of this system was Dr. Michael Fessenden, the Medical Director of the 360 10 Case Document 12 Filed 08/04/20 Page 11 of 64 program. Dr. Fessenden designed or improved on a check?the-box form known as a ?360 Comprehensive Assessment? (the ?360 Form?) which providers were required to complete in order to document each 360 encounter. The 360 Form was ?comprehensive? in the sense that it reflected health pro?le of all biological systems based on the totality of the information obtained during the AWV and physical exam portions of the 360. That is to say the 360 Form combined in a single document information that would typically be collected in the course of an AWV (?Collected Health Information?), such as a list of medications, the patient?s medical history and a self-assessment of health status, as well as information that would typically be obtained in the course of performing a routine physical examine (?Clinical Data?), such as heart rate, blood pressure and observable health problems. 34. However, in doing this the 360 Form made no distinction as to source of the information reported by the examining provider. In other words the 360 Form did not require the examining provider to state whether the information he or she was reporting derived from Collected Health Information or Clinical Data. This was important because the AWV and physical exam served different purposes. The AWV is a form of preventative health consultation that evaluates the patient based on the patient?s self-assessment of his or her health status. The physical exam, on the other hand, is an assessment of health status based on a medical professional?s evaluation of clinical signs and Findings from the AWV rely on anecdotal evidence of health status, while ?ndings from the physical exam rely on empirical data and clinical analysis. 35. The Form required the examining provider to report the information indiscriminately and draw conclusions on current health status from the totality of this information. As a result, any diagnoses made from performing the 3605 lacked accuracy because 11 Case Document 12 Filed 08/04/20 Page 12 of 64 the type of evidence upon which the conclusions relied could have been drawn from either source. In fact there are documented instances of misdiagnoses which occurred due to examining providers reaching clinical diagnoses on the basis of anecdotal evidence, and Cigna? was aware that this was happening. An example of one such misdiagnosis is documented in an email exchange attached as Exhibit A. 36. Even with chronic illnesses that are considered ?permanent,? reporting diagnoses on the basis of anecdotal evidence was improper because unless the examining provider has clinical knowledge of prior health conditions the diagnoses are still unreliable because they do not take into account the possibility that the health conditions may have been misdiagnosed or that the patient was stating the wrong diagnoses. Performance of the 3605 37. was fully aware that 3608 were unreliable when performed by providers unfamiliar with the patient?s health history, and for this reason it sought to recruit PCPs to perform them. offered PCPs a $150 bonus per completed exam if the PCPS would perform a certain volume of 3603 each year for their patients. Those PCPs choosing to participate in the program were also paid $1,000 each time they attended a 360 training seminar held by The purpose of these training seminars was to teach PCPs how to leverage information obtained from the AWV to find high revenue diagnoses. 38. However, despite efforts to recruit PCPs, many PCPs were unable or unwilling to perform the 3605 for their patients. Nevertheless, determined to complete as many 360s as possible, attempted to complete the 360s anyway by turning to third party contract providers (?Contract Providers?) who could visit the Plan 12 Case Document 12 Filed 08/04/20 Page 13 of 64 Members in their homes to perform the 3605. For the most part these Contract Providers completed 3605 through the use of nurse practitioners 39. Between 2012 and 2017 used 6 Contract Providers nationwide to complete 3603. Alegis, being a Cigna af?liate, was the largest Contract Provider by 360 volume. THM was the second largest Contract Provider by volume, and the largest independent Contract Provider. Each year Alegis and THM accounted for approximately 60% of all of the 360s performed for the MA Plan. 40. If and when it became clear that a PCP would not perform a 360 for a patient, would add the patient?s name and contact information to a ?target list? that it compiled and distributed to each Contract Provider based on the market in which the Contract Provider operated. For each Plan Member name that distributed, Cigna? also included two .txt ?les that jointly comprised a document known as a ?health management report? (?Historical One of these ?les contained a list of the Plan Member?s medications and the date on which they were last reviewed. The second ?le included a list of diagnoses previously reported to CMS, but did not indicate the date on which these diagnoses were reported. 41. Contract Providers would reach out to Plan Members to schedule the in-home 3603. If a Contract Provider made contact and scheduled the appointment, a NP would be sent to the Plan Member?s home and would perform the 360 in accordance with speci?c instructions provided by The NPs were not permitted to deviate from these instructions. 42. Most Contract Providers performed the 360, completed the 360 Form and then submitted the 360 Form directly to for approval. In case, once the 360 Forms were completed they were transmitted to corporate office for processing. The 13 Case Document 12 Filed 08/04/20 Page 14 of 64 360 Forms were reviewed by ?coders? who analyzed the information and then interfaced with the examining NPs to understand the reported conditions and assign 1CD Codes to these conditions. This interaction was necessary because in many cases the 360 Forms contained information that was inconsistent and needed correction or ambiguous and required clari?cation. 43. Once coding was completed, THM summarized the ICD Codes in a report that was intended to supplement the Historical HMR (the ?Supplemental The Supplemental HMR and the 360 Form were then combined into a single electronic document (the ?Comprehensive Form?), a copy of which is attached as Exhibit B. Upon completing the Comprehensive Form, a copy was securely transmitted to and the Plan Member?s PCP. 44. On numerous occasions THM managers made clear to executives at Cigna? that any health conditions and related 1CD Codes recorded in the Comprehensive Form were to be used only as a recommendations to the PCPs for review, and that they did not represent con?rmed medical diagnoses. This was because the NPs were not physicians, they were not trained to diagnose chronic health conditions, they did not have regular encounters with the Plan Members and they were not furnished with any information regarding the health conditions of the Plan Members other than the limited information in the Historical HMR. THM did not want to use any information in the 360 Forms, in particular the ICD Codes, in reporting Risk Adjustment Data to CMS unless and until the PCP approved this information and incorporated the Comprehensive Form, including the Supplemental HMR, into the Plan Member?s medical records. 45. In order to avoid misuse of the reported information, each Comprehensive Form included a cover page that instructed the PCP to review the information in the Comprehensive l4 Case Document 12 Filed 08/04/20 Page 15 of 64 Form before incorporating it into the Plan Member?s medical records. The cover page also stated that ?[t]he home visit is not a substitute for PCP treatment and DOES NOT replace the annual physical or HMR completed by the 46. other Contract Providers also provided similar disclaimers on the cover page of the 360 Forms they reported. The cover page to Alegis?s form for example states ?[t]he visit was solely for the purpose of updating the insurance provider?s information regarding the patient and their condition.? A representative example of Alegis? 360 Form is attached as Exhibit C. 47. In spite of these disclaimers, without confirming that the PCPs had reviewed, approved and incorporated the 360 Forms into the Plan Member?s medical records, Ci gna? reported the ICD Codes to CMS as Risk Adjustment Data representing the Codes as con?rmed medical diagnoses. The 2017 Arbitration Proceeding 48. misreporting of 1CD Codes as well as other misconduct was discovered by the Relator in 2017. In early 2017 THM and became embroiled in a contract dispute which ultimately forced THM to seek emergency measures of protection in arbitration with the American Arbitration Association (the ?Arbitration?). During an emergency hearing it came to light that had been misusing the information reported by THM and its other Contract Providers in the 360 Forms. 49. Medical Director, Dr. Michael Fessenden, testified under oath that the codes reported by THM did not need to be used because they merely repeated diagnoses described in the 360 Report. He also testi?ed that the reason furnished Contract Providers with Historical HMRs was to provide them with a ?cheat sheet? to 15 Case Document 12 Filed 08/04/20 Page 16 of 64 ensure that the health conditions identi?ed in the Historical HMR were re?validated during the 360 and/or to allow Contract Provider to ?nd new related chronic health conditions. 50. During the discovery phase of the Arbitration reports were disclosed in which evaluated the performance of each Contract Provider based on ?retention rates,? or the percentage of chronic health conditions that the providers were able to retain or reuvalidate during the 360 as compared to the conditions reported in the previous year. set a ?goal? of re?validating 85% of all previously-identi?ed chronic conditions by the end of each year. 51. In addition to the retention rates, these reports set forth the Contract Provider?s performance in capturing illnesses in 12 generic disease classes consisting of chronic diagnoses which are ?often underdiagnosed.? The Contract Provider?s results were compared to ?all the vendors and to a competitor.? If the generic diseases were not identi?ed by the Contract Provider at all during the exams, then would ?ag those underdiagnosed diseases in red, and if there was more than a 3% difference than a competitor, then Ci would flag the diseases in yellow. Contract Providers were also evaluated based on the impact of the diagnoses on the Plan Members? risk scores. 52. It was discovered that Contract Providers with the highest retention rates and risk score increases would be rewarded with additional business volume. Contract Providers with lowest retention rates would be forced to attend educational seminars in which Cigna? employees would provide information on how to re?validate the high value chronic conditions that the Contract Provider previously failed to identify. 16 Case Document 12 Filed 08/04/20 Page 17 of 64 CAUSE OF ACTION VIOLATION OF 31 U.S.C. 3729(a)(1) 53. Relator realleges and incorporates by reference the allegations made in Paragraphs 1 through 52 of this Complaint. 54. Under 31 U.S.C. 3729(a)(l)(A) a person may not knowingly present, or cause to be presented, a false or fraudulent claim for payment or approval by the federal government. In order to comply with this statutory requirement, claims submitted by a MA Organization to CMS for risk adjustments to payments must satisfy the requirements of 42 CFR 422.310, including the requirement that the sources and extent of submitted data comply with CMS requirements. As a condition to receiving payments, The MA Organization is required to certify the accuracy, completeness and truthfulness of the submitted data. 42 CFR 422.5040). 55. Under Section 120.1 of the Medicare Managed Care Manual with respect to physicians (including nurse practitioners), only diagnoses ?rendered? as a result of a physician Visit are relevant data for risk adjustment purposes. Section 40 of the MMCM further provides that all diagnostic codes submitted by a MA Organization ?must be documented in the medical record and documented as a result of a face~to?face Visit.? 56. Since at least as early as 2012, has knowingly presented false and fraudulent claims to CMS for payment because the ICD Codes reported in connection with these claims referred to health conditions of Medicare beneficiaries that (1) did not exist, (2) were not documented in any medical records and (3) were not based on clinically reliable information. 17 Case Document 12 Filed 08/04/20 Page 18 of 64 Health Conditions that did not Exist 57. Some of the health conditions represented by the ICD Codes did not represent existing health conditions because they derived from 360 Forms which set forth clinical data that contradicted the diagnoses. For example in one of the 360 Forms completed by Alegis, new chronic conditions were added for the patient that included dementia and COPD even though the NP noted on the 360 Form that mental and resniratory functions were ?normal.? Ci gna? knew that the information was false because it employed a team of coders and that examined each and every 360 Form for accuracy and internal consistency. 58. Ci also knew or should have known that false health conditions were being reported because it was actively encouraging Contract Providers to falsify diagnoses in 360 Forms. trained providers on ways to render high value diagnoses based on anecdotal evidence collected during the AWV portion of the 360. In educational seminars led by Dr. essenden, attendees were taught to ?paint a picture? of an adverse condition in the 360 Forms by including notes that could link any signs or from the physical exam to prior health conditions in the Historical HMR. At one seminar attended by employees of THM, Dr. Fessenden advised attendees that they could diagnose rheumatoid arthritis if they simply noted in their 360 Forms pain in the wrists, proximal interphalangeal joints and metacarpophalangeal joints with morning stiffness lasting more than 1 hour and (2) systemic of fatigue and weight loss. These are common to numerous illnesses. Health Conditions that were not Documented in any Medical Records 59. In addition to the health conditions that did not exist, the vast majority of health conditions reported by Ci from Contract Providers were not documented in any medical records as required by Section 40 of MMCM. 18 ‫‪Case 7:17-cv-07515-KMK Document 12 Filed 08/04/20 Page 19 of 64‬‬ ‫ﺀ‪ (٦‬ﺀﺃ ‪٥‬ﺀ<(ﺃ(ﺀﺀ‪٥‬ﺃ‬ ‫ﺩﺩﻫﺄ(ﺃﺃ‪،‬ﻩﺀ ﺍ(ﺍﺩﺀﺍﺍ ﺀ‪( (١‬ﺩ(( ﺀ(>ﺩﺀﺀ (ﻩ ‪٥٦‬ﺃ‪ ٥‬ﻩ ﺩﺍﺩ ﺀﺀﻧﻪ(‪ 5‬ﺍ(ﺍﻩ ﺀﻻ<ﺩ_ﺃﺀ‬ ‫‪ .‬ﺍ~‬ ‫ﺀ‪ ٠‬ﻩ ﺀ‪):‬ﺀ ‪ ٠٧‬ﻩ( ﺩ‪ ٢ ) 2٥1‬ﺀ(‪ ٠‬ﺩﺀﻻ‪ ٠‬ﺩﺍ<‪ ٠‬ﺀﺍﺩﺀ ﺍﺩ( ﺩﺀ‪.،‬ﺩ‪ ٦‬ﺀ ﺍﻩ ﺀ‪:‬ﺀﻩ‪ 1‬ﻩ~ﻩ‪(٦‬ﺀ ‪ ٤٧‬ﻩ ﺀﺀﺃﺍﻩ ‪ ٨‬ﺀ‌«‪ ٠‬ﻩ‪.‬ﺃ ‪٨‬‬ Case Document 12 Filed 08/04/20 Page 20 of 64 Form is not, in and of itself, part of the medical records. In case, every completed Comprehensive Form that was submitted to and reviewed and accepted by included a cover page that stated that the Comprehensive Form did not constitute an annual physical exam or replace any historical health records which are completed by a PCP, and it instructed the PCP to review the information before incorporating it into the Plan Member?s medical records. The cover page to Alegis? 360 Forms similarly stated that ?[t]he visit was solely for the purpose of updating the insurance provider?s information regarding the patient and their condition.? (see Exhibit C). ignored these disclaimers and submitted 1CD Codes for hundreds of thousands of encounters without any continuation that the 360 results had been properly incorporated. 63. submitted these 1CD Codes knowing that it was wrong to do so. Dr. Michael Fessenden exchanged emails with employees in which reveal that he was aware that PCPs had not in some cases received copies of the 360 Forms, and he instructed managers to send them months after the 3603 were completed so as to avoid any potential accusations of ?upcoding? due to the fact that the health conditions reported to CMS did not match the health records maintained by the Plan Member?s PCP. 64. The 360 Forms also do not constitute valid medical records because they were completed by NPs who under applicable law of the state where they were licensed did not have the authority to independently render medical diagnoses. Texas Nursing Practice Act that the term ?professional nursing? does not include act of medical diagnosis). The NPs did not have the authority to render medical diagnoses without collaboration with a physician to con?rm that the diagnoses were accurate. did inquire as 20 Case Document 12 Filed 08/04/20 Page 21 of 64 to the level of authority granted to any of the NPs who performed 3603, nor did they ever con?rm that any collaboration occurred. Health Conditions that were not Based on Clinically Reliable Information 65. Most if not all of the health conditions reported by Contract Providers and re?ected in the Codes were derived from 360 Forms that were not clinically reliable. NPs diagnosed chronic and acute health conditions without conducting any diagnostic tests or obtaining input from any specialists. 66. Instead, NPs rendered clinical diagnoses on the basis of anecdotal evidence. This was due to the way that the 360 Form was designed. The form required that the NPs conduct a review of chronic and acute diseases but only gave them two check-the-box options in completing the review either (1) diagnose the disease or (2) indicate that there is ?no active disease.? If a patient disclosed that he or she had a speci?c condition, then in many cases examining providers diagnosed the condition on the basis of this anecdotal evidence rather than report that there was no active disease. In some cases NPs also rendered diagnoses not based on the Plan Member?s statements but rather medications found in the home. This resulted in unreliable diagnoses because none of the 360 Forms indicate the basis on which the NPs rendered their diagnoses whether they did so on the basis of anecdotal evidence or clinical data). 67. not only knew that the information included in the 360 Forrns was unreliable but in fact encouraged providers to use unreliable information such as the Historical HMRs as a guide in finding active diseases year after year. The Historical HMRS provide nothing more than a list of diagnoses previously submitted to CMS without any dates, notes or even the name of the provider who rendered the diagnoses. With regard to 21 Case Document 12 Filed 08/04/20 Page 22 of 64 prescriptions, they simply list the names of the medications, dosages and the last date on which they were reviewed. The Historical HMRs clearly are not medical records and they were prepared by not the Plan Member?s PCP. They lacked reliability and should not have been relied upon to make a diagnoses. 68. Ci also pushed providers to ?recapture? as many chronic health conditions as possible by forcing Contract Providers to compete with each other to attain the highest diagnosis retention rates possible. Those with the highest rates were rewarded with additional business volume, while those with the lowest rates are punished with reduced business volume and they are required to attend educational seminars focused on techniques to increase diagnosis recapture. 69. To further encourage competition, performance reports were distributed to Contract Providers that highlighted their retention rates as compared to the other Contract Providers, as well as the percentage of diagnoses that were ?lost? from the medical charts. To keep competition robust, ensured that at least two Contract Providers operated in each local market. 70. also entered into contracts with some Contract Providers that paid bonuses for achieving higher retention rates. For example one such provider was contractually entitled to receive Chronic Retention Rate Compensation payment if the provider?s annual chronic retention rate were to exceed 80%. 71. also intended to recapture diagnoses by having PCPS use a tool called Lumeris to report all diagnoses so that a list of health conditions could be compiled and provided to the Contract Providers to ensure that all reported diagnoses were re?validated 22 Case Document 12 Filed 08/04/20 Page 23 of 64 year to year. paid PCPS $250 to record each diagnosis in Lumeris but did not provide them any ?nancial incentives to report any resolved health conditions. 72. misconduct comes of no surprise. has a longstanding history of regulatory violations, and has received numerous notices of non? compliance, warning letters and corrective actions plans from CMS over the past several years. See CMS Notice of Imposition of Immediate Intermediate Sanctions, dated January 21, 2016, relating to failure to comply with 42 C.F.R. Part 422 and 42 C.F.R. 423. Most recently, on January 21, 2016 was sanctioned for failing to abide by CMS compliance program requirements and was stripped of its ability to accept new enrollees in its MA Plan. 1d. 73. Through the acts described above, Defendants knowingly presented to CMS false and fraudulent claims for risk adjustments to its capitated rate. CMS, unaware that these claims were false and fraudulent and relying on the certi?cation provided by the Defendants pursuant to 42 CFR 422.5040), paid Defendants amounts that it would not have otherwise paid had it been aware that health conditions of the Plan Members were misrepresented. 74. Due to conduct, the United States of America, acting through CMS, has overpaid on claims deriving from over 375,000 360 encounters, overpayrnents that on information and belief exceed $1.4 billion in the aggregate. PRAYER WHEREFORE, quz? tam plaintiff Robert A. Cutler prays for judgment against Defendants as follows: 1. That Defendants cease and desist from violating 31 U.S.C. 3279?33; 23 ‫‪Case 7:17-cv-07515-KMK Document 12 Filed 08/04/20 Page 24 of 64‬‬ ‫‪:‬ﺃ))) ﺩ ﺀ‪.‬ﺩ‪.‬ﻻ ﺍ ) (ﻩ‬ ‫‪(:‬ﺀ ‪٩‬‬ ‫ﺩ‪-‬ﺃﺩﺍﺀ ﺀﺩ‪ 1‬ﺀ( ﺍﻩ‪ ٠‬ﺀﺍﺀﺀﺀ>ﺍ( (ﻩ )ﺃ(‪))) ٥‬‬ ‫ﺩ‪<-‬ﺀﺀﻩ ‪> ٠٨‬ﺀ ﺀ(( ﺩﻩ ﺃﺀﺃﺍﺀ‪»‌،‬ﺀ<ﺃ(‌«ﺍﺀ<ﺩ‪ 1‬ﺍﻩ ﺀﻩﺃﺀﺀﺀﺩ ﺩﻩ(ﻩ ﺍﺀ ‪ ٩‬ﺍ‪،‬ﺩﺩ ﺩﺀﺍﺩﺍ‪ 5‬ﺃﺀﺍﺃﻩ‬ ‫ﺀ(ﺍ ﺍﻩ‪( ٦‬‬ ‫‪5.‬‬ Case Document 12 Filed 08/04/20 Page 25 of 64 CERTIFICATE OF SERVICE I hereby certify that on the 19th day of September, 2017, I forwarded the foregoing document via certi?ed mail to the following: Civil Process Clerk United States Attorney?s Office Southern District of New York 300 Quarropas Street White Plains, NY 10601?4150 Lee J. Lo?hus Assistant Attorney General for Administration US. Department of Justice Justice Management Division 950 Avenue, NW Room 1111 Washington, D.C. 20530 Pro Hac Vice robertcutleresq@gmail.com Law Office of Robert A. Cutler 100 Partrick Road Westport, CT 06880 Tel: (347) 449?0448 25 Case Document 12 Filed 08/04/20 Page 26 of 64 EXHIBIT A 25 ‫‪Case 7:17-cv-07515-KMK Document‬‬ ‫()ﺀﺀﺃﺍ(ﻩ‪.‬ﺀﻫﻪ‪1‬ﺍ‪12٠‬‬ ‫‪Filed 08/04/20‬‬ ‫‪٩1‬ﺀ‪27‬‬ ‫ﺀ<ﺍ‪of‬‬ ‫‪«‌> 5(.‬ﺀ‪-‬ﺀﻩﺍ‪«.‬ﺩ‪ ٠‬ﺩﻩ‪.‬ﻩ‪64‬‬ ‫ﻫﺎﺍ‪:‬ﺩﻡ ﺍﺍﺃ‬ ‫‪Page‬ﺀ‌»><ﻩﺀ‪1.‬‬ ‫ﺃﺍﺩﻻ‪،‬ﺀ<>‬ ‫‌«>ﻩ‬ ‫•ﻡﻡ ﻡﻡ‬ ‫ﺭ ﻡ ﻡﺭ‬ ‫ﺭﻡ‬ ‫‪.‬ﻡ ﻡ ﺭﻡ ﻝ‬ ‫ﻡ ﻡ ﻟﻢ ‪٠‬‬ ‫ﺍﻯﻡ‬ ‫ﺭﺭﻡ‬ ‫ﺳﺮ‬ ‫‪Case 7:17-cv-07515-KMK Document 12 Filed 08/04/20 Page 28 of 64‬‬ ‫ﻝ ﻉﺳﺮﻡ ﻉ ﺡ ﻉ ﻡ‬ ‫ﻯﻡ ﻡ ﻡ‬ ‫ﻯﻡ ﻡ ﻉ ﺯﻡ‬ ‫ﻡ‬ ‫ﻭﺡ ﻭ ﻯﻡ ﻡ‬ ‫ﺭﻡ ﻡ‬ ‫ﻭﻭ ﻡ ﺯﻉ ﻡ ﺭ‬ ‫ﻝ ﻉﻡ‬ ‫ﻡ~‬ ‫ﻡ ﻩ‬ ‫ﻭﺭ‪.‬ﺱ ﻡ ﺯ ﻉ ﻡ ﺡ‬ ‫ﻯﻝ ﻡ‬ ‫ﻝ ﻉ ﻡ ﺡ ﻉ ﺭﻡ ﻭﺡ ﻉ ﺱ‬ ‫ﻡﺕ‬ ‫ﻯﻡ‬ ‫ﺭﺩﻯﻯﻡ‬ ‫ﺀ~ﻯ ﻣﺮﻡ ﻡ‬ ‫ﻭﻯﻉ ﻡ‬ ‫ﺭﺭﻯ‬ ‫ﻡ‬ ‫ﻝ ﻡ ﻭ‬ ‫ﻡ~ﻡ ﻡ ﺭﻡ‬ ‫ﻭ~ﺭ~‬ ‫ﻡ ﻭﺯﻡ‬ ‫ﻡ ﻉ ﻡ ﻣﺮ‬ ‫ﺭ~‬ ‫ﻝ‬ ‫ﻝ‬ ‫ﺭﻭ‬ ‫ﺭﻉ ﻡ ﻉ ﺱ ﻡ ﻣﺮﺹ ﻭ‬ ‫ﺯ‬ ‫ﺭﻣﺮﻡ ﻭﻡ ﺭﺯ ﻡ ﻯﺡ ﻡ ﻡ ﻭﻯ ﺡ‬ ‫ﺭﻡ~ﻡ ﻡ ﺯ ﻯ‪ ٠‬ﻡ ﻡ ﺡ ﺯﻡ‬ ‫ﻉ_‬ ‫ﺭﺭ ﻉ ﻣﻢ‬ ‫ﻭﻡ ﺡ ﺯﺭ‬ ‫ﻝ ﻯﺭﻡ‬ ‫ﺭﻡ ﺱ ﻉ ﻣﻢ ﻡ ﻭﻟﻢ ﻡ ﻉ~ ﻛﻞ ﺡ ﻭ‬ ‫ﺭ~ ﻉ ﻡ ﻡ ﻡ‬ ‫ﻭﻯﻉ ﻡ‬ ‫ﻡ ﻯﻉ ﺱ ﺡ‬ ‫ﺭﺭ‬ ‫ﺭﻡ ﻡ‬ ‫ﺭﻡ‬ ‫ﻯﻡﺕ ﻡ‬ ‫ﻭﻯ ﻡ‬ ‫ﻯﺯﺭﻡ‬ ‫ﻣﺮﺭﺡ ﻉ ﻉ ﺭﻡ‬ ‫ﻭﻯﺭﻡ ﻡ‬ ‫ﺭﺭﻭﻡ‬ ‫ﻭﻡ‬ ‫ﻡ ﻉ ﻡ ﺱ‬ ‫ﺭﻉ ﻡ ﺭ ﻡ‬ ‫ﻡ‬ ‫ﺱ‬ ‫ﻭ‪-‬ﻡ‬ ‫ﻻﻉ ﻣﻢ‬ ‫ﺭﻡ ﻡ‬ ‫ﺭﻣﺮﻡ‬ ‫ﻭﺭﺡ ﻡ‬ ‫ﻝ‬ ‫ﺭ‬ ‫ﻡ~(ﻡ‬ ‫ﺭﺭ‬ ‫ﻉ‪-‬‬ ‫~ﻡ ﺭﺡ ﻉ ﺡ‬ ‫ﺭﺭﻯﺯﻡ‬ ‫ﻭﺭﺱ ﺹ ﺭﻡ ﻉ ﻡ ﻡ‬ ‫ﺭﺭ‬ ‫ﻭﻡ‬ ‫ﺭﻉ ﻡ‬ ‫ﻯﻉ~ﻭ ﻡ‬ ‫ﺭﺭﺭ‬ ‫ﻭ‪/‬ﻡ ﻡ ﺡ ﺯﺭﻡ ﺱ ﻡ ﻉ ﺡ ﻉ‬ ‫ﻯﺭﻉ ﺭﻭ‬ ‫~ﻡ ﻉ ﻡ ﻉ‬ ‫ﻯﺭﻉ ﻡ‪-‬‬ ‫ﻻﺭﺭ‬ ‫ﻯﺭﻭﺭ ﻡ‬ ‫ﺭﻭ ﻉ ﻡ ﻻ‬ ‫ﻭﺭ‬ ‫~‬ ‫ﺡ ﻭﻡ ﻭﺡ ﻉ ﻡ ﻡ‬ ‫ﻭﻡ‬ ‫ﺭﻭﻣﺮ‬ ‫ﻡﻡ ﻉﺡ‬ ‫ﺭﻉ‪.‬ﻡ‬ ‫ﺳﺮﺭﺭ‬ ‫ﺭﻭﺭ‬ ‫ﺭﻭﺭ ‪/‬ﻡ‬ ‫ﻫﺮﻭﺡ ﻛﻞ ﺡ ﻭ ﻡ ﻉ ﻡ ﻡ‬ ‫ﺭﻭ ﻉ ﻡ ﻡ ﻡ‬ ‫ﺯﻭﺭﻭﺡ‬ ‫ﺭﻭﺯﻡ‬ ‫ﻣﺮﻭﻡ ﻡ ﺱ ﻉ‬ ‫ﺱ ﻭﻡ‬ ‫ﻉ‪-‬‬ ‫ﺭﻡ ﻡ‬ ‫ﻯ‪.‬ﺭﻡ ﻉ‬ ‫ﺭﻭﻫﻢ ﻉ ﻡ‬ ‫ﺭﻭ‪-‬ﺭ‬ ‫ﺭﻉ ﺡ ﻡ‬ ‫ﺭﺭﻡ ﻡ‬ ‫ﻯ‪.‬ﺭﻭﺭﻉ‬ ‫ﻭﺡ ﻭ ﻉ ﻡ ﺭ ﻡ ﻭ ﻉ ﻉ‬ ‫ﺭﺀ‬ ‫ﻡ ﻡ ﺩﻡ ﺭ ﻉﺱ ﺹ ﻭﻯ ﺍ‬ ‫ﺭﻣﺮ ﻯﺀﻯﺹ‬ ‫ﻭﺭ‬ ‫ﺭ‪.‬ﻝ‬ ‫ﻡﻡﻡ‬ ‫ﻯﻉ‬ ‫ﻯﻡ ﻡ‬ ‫ﺭ~‪/‬‬ ‫ﺭﻉ ﺭﺯﻛﻞ ﻭ ﻛﻞ ﻯﻯﺯﻡ ﻭﻣﺮ‬ ‫ﻭﻝ‬ ‫ﺭﻡ ﻉ‪.‬ﻡ‬ ‫ﻯﺭﻭﻡ‬ ‫ﻭﻡ‬ ‫ﺭﻭ ﻉ ﻡ ﻡ‬ ‫ﻯﻣﺮﺭﻡ‬ ‫ﻯﻡ ﻯ‬ ‫ﻣﻮﻡ ﺹ ﻡ ﻉ ﻡ ﻡ ﻛﻞ ﻉ ﻡ‬ ‫ﻡ ﻭﺯﻡ ﻭﻡ ﻡ ﺯﺭﻻﺕ ﺇ ﻡ‬ ‫ﻭﺭﻡ ﻡ ﻡ‬ ‫ﻝ ﻡ ﺭ ﻡ ﻯﻡ ﺯﻡ ﻉ ﻡ ﻡ ﻡ ﻭ ﻯﻡ‬ ‫ﺭﻉ ﻣﺮ ﻡﻟﻢ‬ ‫ﻭﻡ ﻯ‬ ‫ﺭﺩﻡ ﻡ ﻭ‬ ‫ﻡ ‪٨‬ﺭﻟﻢ ﺡ ﻡ ﻟﻤﻢ‬ ‫ﺭﻉﺕ ﺳﺮﻉ ﺭ ﻫﻢ ‪ ٨‬ﻭ‬ ‫ﻯﻭ ‪ ٨‬ﻡ ﻡ ﻉﺕ ﻡ‬ ‫ﻭﻭ‬ ‫ﻭ~ﻭﻟﻤﻢ ﻉ ‪ ٨‬ﻯ‬ ‫ﻭﻯ‬ ‫ﻡ ﻉ ﻉ ﻡ ﺡ ﻯ ﻛﻞ ﻉ ﻛﻞ ﺱﻟﻢ ﻯﻡﺕ ﻉ ﺳﺮﻭﻟﻤﻢ‬ Case Document 12 Filed 08/04/20 Page 29 of 64 Member name? mom" ao?f?mo/zms Warts: ?fii fink, 'Wt tit-isi: ?iiMi: ?iump W: HR: Gender: [:51 JED Eta - ff?, exam Normal . Abnormal/Findings General I Hearing. Nominl Abnormal Mod, lit-an lung-l 5 Blunt Deferred Abdomen hr} Eximm?iios EU Deferred Muscuiorheleiai Neurological Skin . "ink-Ell [3 if] Deferred Current Cardiovascular: tit-viewed and no active disease Mods Monitor Diet labs Referral History at Mi Sun-div Data-z Angina Focioris 7 El can ill Ci Cardlumvopaiiw Primaw Secondary Ischemir. Cl i: [j (iiasmiic Systolic [3 Combined Systolic/Diastolic [j 3 '"Vnmlividcm'n ?3 Carotid artery sicnosiS [3 i? [1 1mm ?Urination Sick Sinus [j Pacemaker wlo Pacemaker [3 1 Li [3 i3 'lii?vwicnslon Benign Unspeci?ed Dam of diagnosis- llypurmnsivc Heart Disease with Failure- Hypertensive Hem! Dlseasn without Failure L3 Renal Disease Lu 1? llvonricnsi-re Heart and Elena! Disease tieari Failure wlo "nan iaiture other Diagnosis {signify}: Just an Fifi; The NP made a note in the ROS re; palpitations and the pi takes meds {or it; Review of systems Negative :ii :miiat - Taker. marl . NEth'n Pain - low back pain: Musdelinlni Pain Right int-e ram/Hanan an handsNeriign/Dininem - Tater?s mariizine problem; - Sleep annm ?7 4?77 ,7 Medications: (List at medications including with dosage and frequency or attach printed, signed and date list and check here I I No Current Medications x. 2: tgoxin 0.125 mg by mouth every day Naproxen 500 mg by m?l?h ?Vice 3 clay 57] Medications Reviewed Levothyroxtne 25 by mouth every day Pilocarpine 1 git right everyday _i What is ctigoxin? Digoxin is derived from the leaves of a digitalis plant. Digoxin helps make the heart beat stronger and with a more regular Digrixin is used to treat heart failure. Digoxin is also used to treat atrial fibrillation. 3 heart disorder or it 19 atria (the upper chambers of the heart that allow hioorlu, to flow into the head) Sheri Allied, C.M.A Case Document 12 Filed 08/04/20 Page 30 of 64 Medical Coding Operations Manager HealthCare Simpi?rfled Group 1701 legacy Drive, Suite 2000 Friszo, TX 75034 r! - 7 Main: 21541548340 ext; 10:! Direct: 214495?8344 Fax: 214?494-8348 sallLederi?hu Alhliajed ?gmganigs A I'r'ealh'rL'crze .3 .x . in a! iloom From: Wade Sloan Sent: Ihursday. January IA, 2016 8.55 AM To: Sheri Allred Sublect: RE: Change 360 Form No rush, thanks From: Sheri Allred Sent: Thursday, January 14, 2016 8:33 AM To: Wade Sloan Subject: Re: Change 360 Form I writ remove it as soon as I get to the olfrce. 5 Sent horn my lPhone On Ian M. 2016, at 8:34 AM, Wade Sloan wrote: Sheri, wili you please remove this diagnosis and send on to Romana so we can resend the 360? Thanks; Good Afternoon Wade and tool twanted to pass along a little information and see ifwe coutd follow up on it so I can report back tonas Please see email to me in Yellow below and my Question to you guys in Green. Thanks! Hey! Got a Question?wrth mailed me a little earlier With a concern they had on a THM 360. They say that member ID had a 360 completed on 07/10/15 by our in home vendor. There was a Diagnosis of Atrial Fibrillation on this exam. The physician is saying this is not an accurate Diagnosis for this member and we should have this exam corrected, How should we handle this situation? I have copied the email that was sent to me below. HI Clint.15P0ke Wttl?w-about her 360 concern. The patientwad a 360 performed in his home and whenmis PCP, received and reviewed the form she noticed a diagnosis marked that the patient does not name. The NP who performed the exam is? and on page 1it she indicated that the patient has Atrial Fibrillation. The patient does not have this condition and ?Vented to make sure that has correct information and records on therr patients so she had?r call to have the diagnosis removed from your records. Please send this information to Matt so that the patient?s information can be correctedd haVe included screen shots of the first and fourth page of the 360 below. lfyou would please let ?and I know when this has been resolved we would greatly appreciate It. Thank you for all your help. Thanks! Clint Russell Network Operations Representative More from Medicare, More from Life. 105 Decker Court. Suite 1000 Irving, TX 75062 Phone: (903) 714-6248 Fax: 1866-7611-8350 Wade Sloan VP Technology 8: Logistics HealthCare Simplified Group 2701 Legacy Drive #2000 Frisco, TX 75034 214.496.8362 Office i317.??89.5?321l Cell Case Document 12 Filed 08/04/20 Page 31 of 64 EXHIBIT 26 Case Document 12 Filed 08/04/20 Page 32 of 64 360 Comprehensive Physical Exam The 360 Exam is a comprehensive exam designed to focus on preventative health care for our members. The exam is conducted by Bravo Health trained Nurse Practitioners (NPs) in the member?s home. The comprehensive exam includes: . Review of Systems - Medication review Fall risk screening Depression screening . Foot exam The home visit is not a substitute for PCP treatment and DOES NOT replace the annual physicat or HMR completed by the PCP. The member is encouraged to see hislher PCP for all labs and recommended treatment following a 360 exam and the Nurse Practitioners may assist the member in scheduling follow?up visits with the PCP. Upon Receipt (Office Staff) Please confirm the following: 1. Confirm you are the correct PCP 2. Verify the member has a follow?up appointment with PCP Once reviewed, the exam should be ?led into the medical record. if the PCP/Office Staff have any questions regarding the 360 Comprehensive Exam, piease feel free to call Bravo Health at 832-553-3300 ext. 3094. January 2014 ‫‪Case 7:17-cv-07515-KMK Document 12 Filed 08/04/20 Page 33 of 64‬‬ ‫•‬ ‫ﻭﺍﺍﺃﺍﻡ ‪<5‬ﺍﺍﺍﻩ ﺀ ‪ ٢‬ﻩ ﺍﺍﻭﺃﺀ ‪٩2٥١ 5‬‬ ‫• ﻡ‬ ‫ﺭ ( ﻯﺯ‬ ‫ﻡ ﻻ ﺭ ﻯﻡ ﺡ ﺭ ﺱ ﺡ‬ Case Document 12 Filed 08/04/20 Page 34 of 64 Member News.? 1303? DOS: 09/28/2015 *Fall Risk Screening?? wl'reelm??l??a?i' that apply) Depression Screening (18+ y/o) Unable to perform examFb/c 0f Screening not performed because the patient is unable to communicate/answer. Diagnoses (3 OP more coextsting) Have you felt depressed or down-and?out over the past 2 months? "a E) No history 0f falls ?mm" 3 "?0th Have you had a loss ofinterest in things that normally bring you pleasure? Yes (21 No Incontinence . Have you felt fatigued or had a loss of energy recently? (Z) Yes No Visual lm airment . .. El if two or more yes then compiete and document results from either 3: L7) aired function lmob'l't a E) PHQ9 form C) Standard screening tool E) Clinical interview El Environmental hazards Attach Standard Screening Tool or Clinical interview to assessment if completed. El Polypharmacy Pain affecting level of function Urinary Incontinence 53330303 Cognitive impairment During the last 3 months - have you ieaked urine (even a small amount)? Yes No TOTAL number of boxes marked: 5 If Yes, please distribute education material [El Fall Risk (4 or more reported) Review of systems Negative Positive] Findings General Unexplained Fatigue/Weakness fatigue; Night Sweats/Fevers/Chills - Occasional hot flashes HEENT El H'ayfever/Allergies/Congestion - Occasional sinus allergies; Changes in Vision wears Rx glasses for bil myopia Cardiac El Respiratosy 6 Heartburn/reflux/indigestion - frequent reflux GU Fiequent Urination - day] night Musculoskeletal (Z) Back Pain - Occasional neck, low back pain; Muscle/Joint Pain - bil lower leg cramps at night Neurological Headaches - occasional headaches Skin El Sleeping problems - occasional insomnia, unable to get full nights sleep Endocrine (Z) Hematological El *Please assess the overall pain presence in the patient's day life*Plan (Z) Meds PT Other *Pain screening E) [j [j E) Cl (Z) Education Pain doctor [3 Foot exam (Complete for diabetic patients) 1. Ask the patient: Burning, tingling or numbness in feet El Previous foot ulcer El Pain or cramping in calf area during exercise None of these 2. Look at both feet: Cl infection Calluses or corns El Nail disorders None of these Ulceration El Skin breaks CI Foot deformity Key: Sensation - No sensation 3. Check for foot Left Right Dorsaiis pedis Normal Weak Absent Normal Weak El Absent Posterior Tibial (Z) Normal (3 Weak Absent (Z) Normal Weak :1 Absent Eest for neuropathy Left Monofilament El Normal Abnormal Right Monofilament Normal El Abnormal 5. Presence ofdiabetes complications: (check all that apply) (Z) Peripheral neuropathy (Z) Peripheral vascular disease Ulcer Gangrene None of these Amputation (date, side level): Vitals: *Ht *Wt (lbs): Temp BP: Gender: IMEEI Page 2 of 9 2015 Cigna Form 360 Rev 120115 Case 7:17-cv-07515-KMK Document 12 Filed 08/04/20 Page 35 of 64 ٥ ‫ (ﺩ‬٥٥ ( ‫ﺃﺃﺃﻫﺎﺍﻡ ﺩ<ﻩ‬: ٥‫ )ﺍﺃ‬8‫ )ﺍ‬٥٥٥ Case 7:17-cv-07515-KMK Document 12 Filed 08/04/20 Page 36 of 64 ٩2٥١ 5 ‫ ﻩ ﺩﻭﺃﺀ‬٢ ‫ ﺍﺍﺍﺍﻩﺀ‬5‫ﻭﺍﺍﺃﺍﺩ‬ Case 7:17-cv-07515-KMK Document 12 Filed 08/04/20 Page 37 of 64 ‫ﻡ ﻟﻢ ﺡ ﻉ‬. ٩‫ ﺀﻭﺩ‬5 ‫ (ﻩ‬9 ٩2٥15 ‫ ﺍﺍﺍﺍﻩ ﺀﻻ ﻩ<ﺍﻭﺃﺀ‬5‫ﻡ ﺍﺍﺃﺍﺩ‬ Case Document 12 Filed 08/04/20 Page 38 of 64 . Member DOB a; DOS: 09/28/2016 Il Active Neopiasms/Btood Disorders: Reviewed and no active disease Meds Monitor Diet Labs Referral Colon CanCer Coiectomy Date: Chemo Radiation Metastatic and if so,to what sitels)? Breast Cancer Site El Right teft) Date: Treatment: Masectomy I:l Chemo Radiation Hormonaltherapy (j if Ductal Carcinoma in situ El Right Left Metastatic and if so,to what site(s)? Prostate Cancer Prostatectomy Hormonal therapy El Chemo C) Radiation Metastatic and if so,to what site(s)? El Lung Cancer [:Itippet Lobe Lower Lobe Other: Treatment [3 Lobectomy Pneumonectomv Chemo Radiation Metastatic and if so,to what site(s)? Skin Cancer (type and site)? C) Melanoma in Situ (site): Otheir Matignancies (specify): Myelodvspiastic Disease Cl DD Cl DD El (le3 Multiple Myeloma Current in Remission Relapse Drug-induced Neutropenia (specify drug): Anemia: Due to CKD Drug-induced (specify drug): {3 Due to Chemotherapy 8-12 Iron General El Sickie Ceil Other: El mos Other Diagnosis (specify): Neurological: E) Reviewed and no active disease Meds Monitor Diet Labs Referral CVA w/ Cl El :1 Specify late effect: Cognitive El Speech/Language Aphasia El El Other: [j MoriOplegia Dominant Non?Dominant Right Left Cl El Cl (3 Upper Limb (3 Lower Limb Hemiplegia/Hemiparesis El Dominant Non-Dominant Right Left Weakness Dominant [j Non-Dominant El Right Left El History of Trauma El El Hemiplegia/Hemiparesis Dominant Non-Dominant Right Left El [3 El El [3 Monoplegia Dominant Non-Dominant Right E) Left Upper Limb E) Lower Limb [j Quadriplegia [3 (3 Multiple Sclerosis Myasthenia gravis El ALS Cl El Cl El Polyneuropathy from other than diabetes El El El Parkinson's Disease: w/ Dementia w/ behavioral disturbances El El El El Seizures Seizure DisorderiEpiiepsy) El Cl El I2) Other Diagnosis (specify): headaches El Page 6 of 9 2015 Cigna Form 360 Rev i20115 Case Document 12 Filed 08/04/20 Page 39 of 64 Member Macaw 003:.? pos: 09/28/2016 [3 Reviewed and no active disease Meds Monitor Diet Labs Referral Dementia Unspeci?ed El Vascular El Senile w/ Delusions w/ Depression Alzheimer's: w/ Early Onset w/ Late Onset w/ Dementia w/ Dementia and Behavioral Disturbances Depressive Disorder Mild Maior if major: Miid Moderate [3 Severe Ci Ci Cl if maior: Single Episode E) Recurrent [3 Full Remission Partial Remission if severe: w/ w/out Anxiety [j Bipolar Current In Remission Full Partial) [j w/ w/out [3 Current kind: Depressed Manic Mixed )3 Current severity: El Miici [3 Moderate Severe Ci [i Schizophrenia Paranoid Simple I:l Undifferentiated El Ci Disorganized El Other (specify): Ci (3 Alcohol Use Alcohol Abuse )3 Alcohol Dependence In Remission El Substance U58 El Abuse Dependence In Remission specify: II) Other diagnosis (specify): insomnia Preventive Medicine: (Please use if Patient deciines, for scheduled, or for advised) Osteoporosis Screening (6185 y/o) Date 01/28/2016 *Breast Cancer Screening (52-74 y/o, every 27 mo): *Colorectal Cancer Screening (50-75 Date 09/28l2015 Sigmoidoscopy (Every 5 years): *Influenza Vaccine (65+ Date 09/06/2016 Colonoscopy (Every 10 years): Advance care pianning: Date 09/23/2016 Pneumococcai Vaccine (65+ Given Vaccine: Pneumouax (Z) Prevnar Date 09/28/2015 Date Advised Date 09/28/2015 Date 09/28/2014 RESULT: (Z) Information given/Discussion Medical 9ower of Attorney Living Will E) Advanced Directive Planning Page 7 of 9 2015 Cigna Form 360 Rev 120115 ‫‪Case 7:17-cv-07515-KMK Document 12 Filed 08/04/20 Page 40 of 64‬‬ ‫‪( ) ٩‬ﺍ‪٠‬ﺀﺀ‪٩‬‬ ‫‪) ٥) 6‬ﺍ‪ 38‬ﺍ‪ ٥9‬ﺀ(ﺩ‪٩‬‬ ‫~‬ ‫‪ :‬ﺩﺃﺍ‪ ٠‬ﺩﺃ ‪ ١٩٠-‬ﺩﻩ ﺍﺀﺃ ‪٨‬‬ ‫(ﺍ ﺭﻡ ﻭﻡ‬ ‫‪ 2٥16‬ﺍ‪ 1٥‬ﺍ‪ ٥9‬ﺀ‪،‬ﺩ ‪٩‬‬ ‫~‬ ‫‪- :‬ﺩ»ﺀ ﺀﻻﺀ ﺍﻩ ﻩ ﺍ(ﺀ‪8‬‬ ‫ﺡﻟﻢ ﻣﺪﻯﺹ ﻛﻞ‬ ‫ﻟﻢ ﻛﻞ ﻭﺡ ﺯﻡ‬ ‫ﻣﻲ~ﺭ ﺡﺹ ﺭﻡ‬ Case 7:17-cv-07515-KMK Document 12 Filed 08/04/20 Page 41 of 64 ‫ﻟﺮﻭﻭﺡ ﺡ‬ ‫ﻡ ﺡ ﻟﻢ ﻭﻡ‬ ‫ﻭﻡ ﻟﻢ ﻡ‬ ‫ﻡ‬ ‫ﺡ‬. ٥ ‫ ﺃﺍﺩ‬: ٥‫ )ﺍﺩ‬8‫ )ﺍ‬٥18)) :‫)ﺩ‬ 2017 HEALTH MANAGEMENT REPORT (HMR) A) List alt Current/Active Conditions for this Date of Service. Patient DOB: referred to provider (Le. Rx, PT, monitoring, etc). B) MUST provide a brief treatment pian for all active conditions you manage and/or name and speciaity of Code Description Required: Treatment Plan for condition managed by provider OR identify referred-to physician and specialty 200.8 Encounter for other general examination CIRX 1 L21 Monitor Dieti Other: i Referral (name/speciaity): 283.49 Family history of other endocrine, nutritional and metabolic diseases CIRX Monitorl Diet Other: i Referral (name/specialty): 283.3 Family history of diabetes meilitus URX Monitorl [3 Diet: Cl Other: Referral (name/specialty): 282 .49 Family history of ischemic heart disease and other diseases of the circulatory system DRX I Monitorl Cl Dieti Other: Referral (name/specialty): 280.0 Family history of malignant neoplasm of digestive organs DRX 1 [El Monitorl El Dietl Other: I Referral (name/specialty): 298.818 Other dental procedure status DRX I Monitor} Cl Dieti Other: i Referral (name/speciaity): 298.42 Cataract extraction status. left DRX i Monitor CI Dietl Other: Referral (name/speciaity): 298.41 Cataract extraction status, right CIRX 121 Monitorl Diet] Ci Other: Referraf (name/specialty): 298.89 Other speci?ed postprocedural states BR): i I Monitorl Dietl Other: Referrai (name/specialty): 287.898 Personal history of other speci?ed conditions URX I Monitor] Ci Dieti Other: i Referral (name/specialty): 28?.42 Personal history of other diseases of the female genital tract DRX iZi Monitorl Ci Diet] El Other: i Referral (name/specialty): Case 7 Electronically Signed By: Date of service: 09/28/2016 Printed physician name: Signature DO MD I NP PA Please Print Legibly important - Must Ensure: 1 Patient?s Name and DOB have been 2 Review of HMR is reference 3 AH pages signed/dated by 4 Originai HMR placed in entered at the top of this form and in Progress Note for DOS. patient?s chart. are legible. Document 12 Filed 08/04/20 Page 42 of 64 2017 HEALTH MANAGEMENT REPORT (HMR) Patient: Patient DOB: i B) MUST provide a brief treatment plan for ali active conditions you manage and/or name and specialty of i A) List alt Current/Active Conditions for this Date of referred to provider (Le. Rx, PT. monitoring, etc). Service. 287.81 Personal history of (healed) Rx Monitor] Diet] Other: Referral (name/specialty): traumatic fracture Ci Rx IE Monitor] Diet] Other: lReferrai (name/specialty): 286.19 Personai history of other infectious and parasitic diseases 286.69 Ci Rx Monitor] Diet] Other: ]Referral (name/specialty): Personal history of other diseases of the nervous system and sense organs Rx 1E Monitor] Diet] Other: iReferrai (namelspecialty): 28?.891 Personal history of nicotine dependence Other reduced mobility El Rx lE Monitor] Diet] Other: ]Referral (name/specialty): 272.3 Less physical activity/ Lack of Rx Monitor] Diet] Other: Referral (namelspecialty): exercise 291.81 History of fatling Rx 1 Monitor] Diet] Other: ]Referral (namefspecialty): E1151 Type 2 diabetes meilitus with El Rx Monitor] Ci Diet] Other: Referral (name/specialty): diabetic peripheral angiopathy without gangrene Type 2 diabetes metlitus with other diabetic neurological complication HO Essential (primary) hypertension Rx IE Monitor] Diet] Other: LABS Referral (name/specialty): E11.49 Ci Rx lE Monitor] Diet] Other: Referral (name/specialty): J45.20 Mild intermittent asthma, Rx Monitor] Diet] Other: uncomplicated J44.9 Chronic obstructive pulmonary Rx Monitor] Diet] Cl Other: Referral (name/specialty): disease. unspeci?ed 'ji" Referrai (name/specialty): Case 7 Date of service: 09/28/2016 Printed physician name: Electronically Signed By: Signature? oor PA Please Print Legibly Important Must Ensure: 1 Patient's Name and DOB have been entered at the top of this form and are legibie. 2 Review of HMR is reference in Progress Note for DOS. 3 Ali pages signedfdated by 4 Original HMR placed in PHYSICIAN. patient's chart. Document 12 Filed 08/04/20 Page 43 of 64 2017 HEALTH MANAGEMENT REPORT (HMR) Patient: '9 3 Patient DOB: A) List all Current/Active Conditions for this Date of B) MUST provide a brief treatment plan for all active conditions you manage and/or name and specialty of Service. referred to provider Rx, PT, monitoring, etc). R0602 Shortness of breath lZi Rx Monitorl Diet! 1:1 Other: 1 Referral (namefspecialty): M150 Polyesteoarthritis, unspeci?ed RX 1 Monitorl Diet Cl Other: 1 Referral (name/specialty): M5020 Other cervical disc [3 RX 1 Monitorl Diet! Other: Referral (name/specialty): displacement, unspeci?ed cervical region M542 Cervicalgia iZl Rx El Monitorl Dietl [3 Other: [Referral (name/specialty): M5126 Other intervertebraldisc Rx Monitorl CI Dietl El Other: displacement. lumbar region M545 Low back pain [Zl RX [21 Monitor Dietl Cl Other: I Referral (namelspeciatty): K5700 Diverticuiosis of intestine, part Cl RX 1 El Monitorl Dietl Other: I Referral (name/specialty): unspeci?ed, without perforation or abscess without bleeding R600 Localized edema El Rx El Monitorl Diet! Cl Other: Referral (name/specialty): R252 Cramp and spasm 12! Rx 1 121 Monitorl [3 Diet] Ci Other: Referral (name/speciaity): R350 Frequency ofmicturition Rx El Monitorl Dietl Other: Referrai (name/specialty): R351 Nocturia Cl Rx [El Monitorl Dietl Other: lReferral (name/specialty): K21.9 Gastro-esophageal reflux i2! Rx [21 Monitor] El Dietl Other: Referral (name/specialty): disease without esophagitis R5333 Other fatigue Rx l2! Monitor! [3 Dietl Other: lReferrai(namelspecialty): Case 7 Electronicaity Signed By: Date of service: 09/28/2016 Printed physician name: Piease Print Legibiy important - Must Ensure: 1 Patient?s Name and DOB have been 2 Review of HMR is reference 3 All pages signedldated by 4 Original HMR placed in entered at the top of this form and in Progress Note for DOS. PHYSECIAN. patient?s chart. are legible. Document 12 Filed 08/04/20 Page 44 of 64 Patient: A) List all Current/Active Conditions for this Date of Service. 2017 HEALTH MANAGEMENT REPORT (HMR) Patient DOB: referred to provider (Le. Rx, PT, monitoring, etc.) l3) MUST provide a brief treatment plan for all active conditions you manage and/or name and specialty of (347.00 insomnia, unspeci?ed Cl Rx {El Monitor) Cl Diet) El Other: REFERRAL i Referral (name/specialty): H5213 Myopiabilateral Rx I Monitor) Diet) Other: Referral (name/specialty): R51 Headache Rx Monitor) Diet) El Other: Referral (name/specialty): J30.2 Other seasonal allergic rhinitis Rx i Monitor) Cl Dietl Other: Referral (name/specialty): N951 Menopausal and female [3 Rx [[21 Monitori Ci Diet] Cl Other: climacteric states Referral (name/specialty): K08.409 Partial loss of teeth, unspeci?ed El Rx El Monitor) Cl Dietl Other: cause, unspeci?ed class PATIENT WEARS AN UPPER PARTIAL Referral (name/specialty): E669 Obesity, unspeci?ed Rx HE Monitor) Diet) Other: Referral (name/specialty): 268.32 Body mass index (BMI) 32.0- 320, adult Cl Rx Monitor) El Diet) Other: Referral (name/specialty): 279.82 Long term (current) use of El Rx Monitorl Diet) if] Other aspirin LABS Referral (name/specialty): 297.2 Presence of dental prosthetic devlce (complete) (partial) Rx Monitor) [3 Diet) 13 Other: 1 Referral (name/specialty): 297.3 Presence of spectacles and contact lenses Rx Monitor) El Diet) [3 Other: Referral (name/specialty): Electronically Signed By: Important Must Ensure: Signature oor PA 1 Patient?s Name and DOB have been entered at the top of this form and in are legible. Date of service: 09/28/2016 Printed physician name: 2 Review of HMR is reference Progress Note for DOS. 3 All pages signedfdated by 4 Original HMR placed in Please Print Legibly patient?s chart. Case 7 Document 12 Filed 08/04/20 Page 45 of 64 Member Name: Member ED: 780915483 Page 1 DOS Code Description -. Source Error Notes(inciude Expianation for "other "Source) 09/28/2016 200.8 Encounter for other general examination Prog Note Other No Sign/Dt Disch Cons Sum Note 09/28/2016 283.49 Family history of other endocrine. nutritional and metabolic diseases Prog Note Other No Sign/Dt Disch Cons Sum Note 09/28/2016 283.3 Family history of diabetes metlitus Prog Note Disch Cons Sum Note Other No Sign/Dr 09/28/2016 282.49 Family history of ischemic heart disease and other diseases of the circulatory system Prog Note Other No Sign/Dt Disch Cons Sum Note 09/28/2018 280.0 Family history of malignant neoplasm of digestive organs Prog Note Disch Cons Sum Note Other No Sign/0t 09/28/2018 298.818 Other dental procedure status Prog Note Other No Sign/Dt Disch Cons Sum Note 09/28/2016 298.42 Cataract extraction status, ieft Prog Note Other No Sign/0t Disch Cons Sum Note 09/28/2016 298.41 Cataract extraction status, right Prog Note Other No Sign/Dt Disch Cons Sum Note 09/28/2016 298.89 Other specified postprocedurai states Prog Note Disch Cons Sum Note Other No Sign/D?s 09/28/2016 287.898 Personal history of other speci?ed conditions Prog Note Other No Sign/Dt Disch Cons Sum Note 09/28/2016 287.42 Personal history of other diseases of the female genital tract Prog Note Other No Sign/0t Disch Cons Sum Note 09/28/2018 287.81 Personal history of (healed) traumatic fracture Prog Note Other No Sign/0t Disch Cons Sum Note 09/28/2016 286.19 Personal history of other infectious and parasitic diseases Prog Note Disch Cons Sum Note Other No Sign/Dt 09/28/2018 288.69 Personal history of other diseases of the nervous system and sense organs Prog Note Other No Sign/0t Disch Cons Sum Note 09/28/2015 287.891 Personal history of nicotine dependence Frog Note Other No Sign/Dt Disch Cons Sum Note 09/28/2016 Reviewer signature Date Case 7 Document 12 Filed 08/04/20 Page 46 of 64 Member Name: 2.43!? DOB: .. Member ID: T80915483 09/28/2016 274.09 Other reduced mobility Note Oisch Sum Cons Note Other No Sign/0t 09/28/2016 272.3 Less physical activity/ Lack of exercise Frog Note Disch Sum Cons Note Other No Sign/Dt 09/28/2016 Z9181 History of faliing Prog Note Disch Sum Cons Note Other No Sign/Dt 09/28/2018 ?11.51 Type 2 diabetes metlitus with diabetic peripheral angiopathy wtthout gangrene Prog Note Disch Sum Cons Note Other No Sign/Dt 09/28/201 8 E1149 Type 2 diabetes mellitus with other diabetic neurological complication Prog Note Disch Sum Cons Note Other No Sign/0t 09/28/2016 I10 Essentiai (primary) hypertension Frog Note Disch Sum Cons Note Other No Sign/0t 09/28/2016 J45.20 Mild intermittent asthma, uncomplicated Prog Note Disch Sum Cons Note Other No Sign/0t 09/28/2016 344.9 Chronic obstructive pulmonary disease, unspeci?ed Prog Note Disch Sum Cons Note Other No Sign/[3t 09/28/2016 R0002 Shortness of breath Prog Note Disch Sum Cons Note Other No Sign/Dt 09/28/2016 M159 unspeci?ed Frog Note Disch Sum Cons Note Other No Sign/Dt 09/28/2016 M5020 Other cervical disc displacement. unspeci?ed cervical region Prog Note Disch Sum Cons Note Other No Sign/0t 09/28/2016 M542 Cervicalgia Frog Note Disch Sum Cons Note Other No Sign/0t 09/28/2016 M5126 Other intervertebrat disc disptacement, lumbar region Prog Note Disch Sum Cons Note Other No Sign/0t 09/28/2016 M545 Low back pain Prog Note Disch Sum Cons Note Other No Sign/Dt 09/28/2016 K5790 Diverticulosis of intestine, part unspeci?ed, without perforation or abscess without bleeding Prog Note Disch Sum Cons Note Other No Sign/0t Reviewer signature 09/28/2016 Date Case Document 12 Filed 08/04/20 Page 47 of 64 Member Name: Dear-ta? Member ED: 780915483 09/28/2016 R600 Localized edema Note Disch Sum Cons Note Other No Sign/Dt 09/28/2016 R252 Cramp and spasm Prog Note Disch Sum Cons Note Other No Sign/Dt 09/28/2016 R350 requenCy of micturition Prog Note Disch Sum Cons Note Other No Sign/0t 09/28/2016 R351 Noctu ria Prog Note Disch Sum Cons Note Other No Sign/0t 09/28/2016 K219 Gastro-esophageal reflux disease without esophagitis Prog Note Disch Sum Cons Note Other No Sign/Dt 09/28/2016 R5383 Other fatigue Prog Note Disch Sum Cons Note Other No Sign/Dt 09/28/2016 (347.00 Insomnia, unspeci?ed Prog Note Disch Sum Cons Note Other No Sign/0t 09/28/2016 H5213 Myopia, bilateral Prog Note Disch Sum Cons Note Other No Sign/Dt 09/28/2016 R51 Headache Frog Note Disch Sum Cons Note Other No Sign/0t 09/28/2016 J30.2 Other seasonal allergic rhinitis Prog Note Disch Sum Cons Note Other No Sign/0t 09/28/2016 N961 Menopausal and female climacteric states Frog Note Disch Sum Cons Note Other No Sign/Dt 09/28/2016 K08.409 Partial loss of teeth, unspeci?ed cause, unsoeci?ed class Prog Note Disch Sum Cons Note Other No Sign/0t 09/28/2016 E669 Obesity, unspecified Prog Note Disch Sum Cons Note Other No Sign/Dt 09/28/2016 268.32 Body mass index (BMI) 32.0-32.9, adutt Frog Note Disch Sum Cons Note Other No Sign/Dt 09/28/2016 279.82 Long term (current) use of aspirin Prog Note Disch Sum Cons Note Other No Sign/0t 09/28/2016 Z972 Presence of dental prosthetic device (complete) (partiat) Prog Note Disch Sum Cons Note Other No Sign/Dt Reviewer signature 09/28/2016 Date Case Document 12 Filed 08/04/20 Page 48 of 64 Member Name: DOB: Member {Dz 780915483 Page 4 09/28/2016 297.3 Presence of spectacles and contact lenses Prog Note Disch Cons Other No Sum Note Sign/[3t 09/28/2016 Reviewer signature Date Case Document 12 Filed 08/04/20 Page 49 of 64 Case Document 12 Filed 08/04/20 Page 50 of 64 EXHIBIT 27 ‫‪Case 7:17-cv-07515-KMK Document 12 Filed 08/04/20 Page 51 of 64‬‬ ‫´ﺍ ‪´ 1‬‬ ‫ﻡﻡﺭﻡﺭ ﺭ ﺭﻡ‬ ‫ﺭﺭﺭﻡ_ﻯﻝﺭ ﺭﺭﺭﺭﻡ‪.‬ﺭ ﺍ‬ ‫‪.‬ﻡﺭﻡ ﻩ ﻝ ﻟﻢ ﻡﺭ‬ ‫´‌ »>ﺃﺍﺩ´ ! ‪ ٩ .‬ﺃﺍ< ﺍ ﺍ‬ ‫ﺭﻡ ﻡ ﺭ ﺡ ‪.‬ﺭ ﺭﻡ ﺭﻡﻡ ﻯﻡﻝ ﺭﻡ ﺭﻡ ﺭﻡ ﺭ ﺡ‬ Case Document 12 Filed 08/04/20 Page 52 of 64 l. 3-2. 1 wExow t, ?5(yeah was I ?If ?an .?r'r' 15-4-3 5 Mam-:13 ?43? I a . 4.235.,? ,1 ?1 51.11:? Patient. Lama: rw?irm?mr PCP i-ic'rrdm'ing ?emdex ?aim: Date: Reagan for Visit: ma; Mien/Smut re. .. .- VETA i. SIGNS: Height in :Jr 3 LIE-L313 ?Mini 359115 Cornmen PAST HISTORY System Diseage xmuimkeaeza; gaunt:-intestinal v. health r: .tirsiir?na' y. . I #3913 ?malmintc'ztr?ui gailbkzudr-r d. 0630/"? {emprehensive 3513' Exam Private Residence; ?59? Fain Store 531 i. . Year Management Year Lurpai tunnc [62219539 1'19 Qumran: E'rtirailhim Die;- HernEu repair Erie? '93 aCCu'ter?? ?935.13 taracurapn'; trar?siam-?rnj; ,rzelinJ'L tub-rs: ?3.3mm Case 7:17-cv-07515-KMK Document 12 Filed 08/04/20 Page 53 of 64 ‫ ﺍﺍ‬:<‫ﺍ ﻻﺍ‬: >.‫ﺩ‬،.‫‌«( ﺍ‬: ٩118 ‫ ﻷﺍﻻﻛﺎ‬5 .‫ﺭﺭﻡ ﺭﻡ‬.‫ﻡ ﻡ ﺭ‬ ( ~‫ﺍ‬١( ١1‫ ﻻ‬٩ ‫ﻷ‬ ‫‪Case 7:17-cv-07515-KMK Document 12 Filed 08/04/20 Page 54 of 64‬‬ ‫ﻡ ﺱ ﺭﺭ ‪.‬ﻡ ﺭ _ ﻡﺭﻟﻢ‬ ‫ﻉ ﻣﺢ ﻡ ﻡ ﻡ ﺡ‬ ‫ﺭﺭ ﻡ ﺭﻡ ﺭ ﺭ‪ ٨‬ﺭﻭ ﻟﺤﺮ ﻩ ﻡ ﻡ ﻡ ﺭﺭ • ﻡ ﻡ ﻫﻲ ﻡ ﺭﻭ ‪.‬ﻟﺤﺮ‬ ‫‪.‬ﺭ ‪ -‬ﻡ ‪.‬ﺭﺭ ( ﺡ ﺭ ﻝ ﺭ ﻧﻲﺯ ﺡﺭﺭ‪ .‬ﻁ‬ ‫ﻡ ﻡ ﺭ ﺡﻟﻢ ﻭ~ﻫﻲ‪-‬ﺭ ‪ .‬ﻉ ﻣﺪ ( ﺑﻲ • • ‪ _.‬ﻡ‬ ‫ﺡﻡ>ﻡ ﺭ ﺭ ﻡﺭ ﺡ ﻡﻟﻢ ﻡ ﺭﻡ‬ ‫• ﻡ ﻫﻢ ﻣﺢ ﻡ • ﺭﻡ ~ﻡ‬ ‫• ﻡ ﻡﺭﻟﻢ ﻡ ﻡ ﺭﻡ ﻡ ﺭ ﻡﻟﻤﺮ‬ ‫ﻣﺮ ﻡ ~ ﺭ ﺭﻡ ﻭﺭﺭ ﻡ‬ ‫‪ -‬ﻡ ﻡ ﺡﺯ ﻡ ﺭﺭ ‪٨‬‬ ‫‪Case 7:17-cv-07515-KMK Document 12 Filed 08/04/20 Page 55 of 64‬‬ ‫`ﻡ`‬ ‫‪ -‬ﺀﻡ‬ ‫ﻱ‬ ‫ﻡ‬ ‫ﻻﻡ‬ ‫ﺭ‬ ‫ﻡﺭ ﺭﻡ ﺭ‬ ‫ﺯ ﻡ ﻡ ﺭﻻ‬ ‫ﻩ ﻡﻡ ﻡﻡ‬ ‫ﺭ‬ ‫ﺭﺭ‬ ‫) ﻡ ﻟﻢ‬ ‫•ﻡ‬ ‫ﻡ(‬ ‫ﺍﺍﺀ‪.‬‬ ‫(‪.‬ﺍ ‪ ١‬ﺩ ﺍ ﺍ‬ ‫ﻝ ﺍ ﺍ ﺍ‬ ‫ﺥ‬ ‫ﺭﻡ ‪ -‬ﻣﻢ ﻡ‬ ‫`‬ ‫ﺍﺍ‬ ‫>ﺍ‌»´‬ ‫ﺍ‪.‬‬ ‫ﺍ‬ ‫ﻡ´ﻥ´‪.‬‬ ‫‪Case 7:17-cv-07515-KMK Document 12 Filed 08/04/20 Page 56 of 64‬‬ ‫‪ ٢1 ١٨95‬ﺃ (‬ ‫‪ ١٩٠‬ﺍﻥ‪،١‬ﺃ ﺍﺍﺍﻯﻃﺔ ﺩ ﻥ •‬ ‫‪ ٠٠‬ﺍ‪)٩‬ﺍ~‬ ‫‪::‬ﻧﺎ‬ ‫‪٨‬‬ ‫´‬ ‫ﻯ ﻡ ﻡ ﻡ ﺭﺭ ﺭ ﻟﻢ ﺯ ‪.‬ﻡ ﻹ >‬ ‫ﺡ ﻡ ‪.‬ﻡ ﺭﺭ ﺱ ﺭ ﺭ‬ ‫ﻣﺮ ﺭﺭ ﻡ ﺭ ﻡ _‬ ‫ﻙ ﻣﻲ ﻭﺭ‬ ‫‪ -‬ﻩ ﺭﺭﻡ ﺡﺏ ﻡﺭ‪ .‬ﻡ ﺭ ﻡ‬ ‫ﻡ ﻡ ﻡ ﺡ ﺭ ﺭﻡ ﻡ ﻣﻲ ﻡ ﻡ‬ ‫ﻡﻻ ﻻ ﺭﻡ ﺭ ﻡ ﺭ ﺳﺮ ﺭ ﻡ ﻡ ﻡ ﻡ ﺭ‬ ‫ﻻ ﻁ ﻉ‪.‬ﺭﻫﺮ ﻭﺭ‬ ‫ﺭ ‪.‬ﺭ ﻡ (ﻡ ﻣﺪ‬ ‫ﻻﺭ ﻡ ﻡ ﻡﺭ‬ ‫ﻡ ﻡ ﻡ‪-‬ﻡﺯ ﻡ ﻡ ﻡ ﻡ ﻡ ﻝ ﻡ‬ ‫ﻟﻴﻢ ﻡ ﻡﺭ ﻟﻢ‪-‬ﺭ • ﻭ‪.‬ﺭﺭ ﺡ ﻡ ﺱﺳﻰ ﻡ ﻡ ﻡ ﻡ ﻝ ﺭ‬ ‫ﻻ ﻡ ﺩ‬ ‫ﻻ • ﺭﺩ‪.‬ﺑﻲ ﻡ ﺱ ﺡ ﻡ ﻫﺮ ﺭ‪~ .‬ﺍ‬ Case 7:17-cv-07515-KMK Document 12 Filed 08/04/20 Page 57 of 64 ‫ﺭ ﺭ ﺭ ﻡ ﻡ ﺍﺯ‬ ‫ﻡ ﺭﻡ‬ ‫ﻯﻡ ﺭ ﻫﻲ‬ ‫ﺯ ﻡ‬ ‫‪Case 7:17-cv-07515-KMK Document 12 Filed 08/04/20 Page 58 of 64‬‬ ‫ﻥ(‬ ‫ﻡ ﺭ‪،.‬‬ ‫ﺍ‪ 3‬ﺍﻧﺎ‪١‬ﻷﻥ ‪~ ٠،‬ﺍﻻﺍ؟ (‬ ‫‪ ٠(٠١٠‬ﺍ) ‪٠.‬‬ ‫ﺍ)ﺍﻻ(ﺫﻥ‬ ‫ﺩﺍﻩ(‪- 1‬ﻩ‪( ٥-‬‬ ‫(ﻷﺀﻩ ﻭﺃ‪5‬‬ ‫((ﺩﻻ ‪٩‬‬ ‫‪٩٥٨‬‬ ‫ﺃﺍﻙ ﺀﺍ ﺍﺩﺍ ‪ ٠‬ﺍﺇﺩ ﺍﻻ_‪ ٠‬ﺩﺀ ﺃ ﺀ‪) ٤‬ﺍ‬ ‫‪...‬ﺭ ﺭ‪.‬ﺭﻡ‪.‬‬ ‫‪ ٠:‬ﻷ‪ <-‬ﺍﻻ ‌« >‪،~ ٠‬ﺍ ﺃ ﺍ(‪(،‬‬ ‫<‪.‬ﺍﺩﻻ‪:‬ﻡ)(‌»‪٠:‬‬ ‫´´‪: ٠‬ﺍﺃﺍﺍﺩﺍ ﺍﺩ‪ ٠‬ﺍﻷ ‪:‬ﻻ ﺃﺀ ﺩﺫﺍ ) ﺀﺍ)ﺍ‬ ‫ﺍ(‬ ‫ﺍﺇ(ﺍﺍﺍ ﻷﺫ‬ ‫ﺇ‪-‬ﺍ ﺀﺍ‬ ‫)>ﺍﺍﺃ‬ ‫ﻻ‪.‬‬ ‫‪ 1‬ﺍﺍﺍ ﺍ‪(:‬ﻻ ﺍﺫﻥ‬ ‫ﻡ ﺡ ﻣﻢ‬ ‫ﻝ ﻡ ﻡ ﺻﺮﻡ ﻷ ) ( ﻟﻢ ﻟﻢ‬ ‫ﻡ ﺇﺭﻡ‬ ‫‪Case 7:17-cv-07515-KMK Document 12 Filed 08/04/20 Page 59 of 64‬‬ ‫‪ ٩ ).‬ﺭﻧﺮﺍﺍﻻ‪>.‬ﺍ‬ ‫ﺀﺍ‪ ٩‬ﺃ‪ )،‬ﺍ‬ ‫‪ 1‬ﺀ( ‪1‬‬ ‫‪ 1‬ﻧﺎ ‪ ٨‬ﺀ ‪ 4‬ﺍ(ﺃ‪.‬ﺃﺃ‪.( ١‬‬ ‫ﻝ ﻓﺮ‬ ‫´‪ ٠.‬ﺃﺍ ﺍﺍ‬ ‫ﻧﺎ ﻟﻢ ﻻ ﻡ ﻡ´‪.‬‬ ‫ﺇﺩﺀ ( ﺍﻡ ﺍ ﺍ ﻩ ﺍ ‪ ١‬ﻡ ﻻ ‪ ٦‬ﺇ ‪ :‬ﺍ ‪٠̀٠‬‬ ‫‪،.‬ﻟﻢ‬ ‫)‬ ‫ﻟﻦ ﻡ ﻡ ﻟﻢ ﻟﻢ‬ ‫‪.٠.‬ﺍ‪<)´.‬‬ ‫‪Case 7:17-cv-07515-KMK Document 12 Filed 08/04/20 Page 60 of 64‬‬ ‫ﺫﻟﻤﺎﻻ( ( ‪ .‬ﺭ ﻥ ﺃ‬ ‫‪٠٠‬‬ ‫‪:‬ﻧﺎ‪ ،٦ ´ ١‬ﻷﻝﻧﺎﺍﻥ ‪٩٠‬ﻥﻧﻬﺎﺍ‪،‬‬ ‫ﺍﺍﺉ ﻧﺎﺍﻙ ﺃ ‪ 9‬ﺍ´‪´. •١‬‬ ‫‪Case 7:17-cv-07515-KMK Document 12 Filed 08/04/20 Page 61 of 64‬‬ ‫ﺩﺍ ﺀﺩﻻﺍ‪ ٠‬ﺀﺍ ~ﺍﺀﺃ‬ ‫‪ .‬ﻷﻻ´ﻣﺎ‪ ١‬ﺍ ﺍ ﻷ ﻧﺄﺍ´‪ ١) ١‬ﺍ‬ ‫ﻻ‪ ٠-.‬ﺍ‬ ‫‪ -١‬ﺍ‬ ‫ﻻﺍﻻﻻ‪.‬ﺍ ‪ ٦‬ﺍﺍ ﺍﺍ~<‪.‬ﺍ‪١‬ﺍ‪ ١~،‬ﺍ‬ ‫ﻡ ﺭﻡ ﻡ‬ ‫ﺭﻡ ﻣﺮ‬ ‫ﻡ ﻣﻲ ﻡ‬ ‫ﻡ‬ ‫ﺭﺭﺭﻡ‬ ‫ﻟﻤﺮﻡ‬ ‫ﻡﺍ ﻡ> ﻡ ﻡ ﻟﻤﺮ ﻡ ﻭﻡ‬ ‫ﺯ ﺭ‪.‬ﻡ • ﻡ ﻡ ﻡ ﻡ‪.‬ﻡ ‪١‬ﺭ ‪٦‬‬ ‫ﻡ ﺭ‬ ‫_ ﻙ ( ﻟﻢ‬ ‫ﺭ‬ ‫ﺭ ﻡ ﻡﻡ ﺭ ﺭﺭ‬ ‫‪ ١١١١‬ﻻ~‬ ‫‪ 1١‬ﻻﺍ‪ ١>١:‬ﺍﻣﺎﺃﺫﻻ ﻷ ‌»ﺩ‬ ‫ﻧﺎﺍ~ﺍ‪( ١‬ﻻﺕ ﺫ ‪ ٨‬ﺃ‬ ‫´ﺀ ﺍ´‪ ٤1‬ﺍ‪ 1٠‬ﻻﺫ ﻧﺎﻷ‬ ‫ﻻ‬ Case Document 12 Filed 08/04/20 Page r-Jorrv'al Imam-(gym - Aha-em hear? rate - rate? .h?hr Hm? nozmrir. - Morn-m 3.1 "?Irnmai Nu: guarn?i- - flu-nurt- Etntirmnizim Herman Hi: mic-Mira I'd-arms; F?ulsea r-J-grmal. ."IE?sdfimen Norma Immaiicn i-iu'zraain - ?30 ?a?mirz"lmr?a zende-?r-M: 340 Muesli: e'nisrgummtl. ?m 5.3mm: enlargement Ewemal gerzilaiiu pelvis; deferred Grpartm Rerfm mam deziinrsd pursc?m View Empewun Nusmni Lumbar - Range of alum: mild xiv-5!, Rfc't'wmt',? I'd-1: edema HeumInquj'a' {dermal buiemory HormaL Cmniui nerve; Cmn?m @6553? intact 1. 'a'wai Ii {Waugh 291.1] MIMI Sonata-f; - - Newt}? Henna! Grenmlen 0:563an in hme. plaw! stluutiun. App'LrihH-Jk? wave-{i and affect Norma? Judgment DEAEETIC FOGT 11*? I (75451,, pagign1 Expggiq-ut?c- hurll'l?tfg, numbness "E?L?ti Hi"- Ewan, graham haw: Dam car cramping in can?! we; mm: min ext-105:2; NC: Ha: m: anti-em had a prewiuu; dull?!" Hi": mm {bl 0- LEFT Fag: Egan" M?mm "3 w- hinging?. ml:- .. fn: {an if?; ?r :mm 3i is- 11:51.35 Case Document 12 Filed 08/04/20 Page 63 of 64 Na? (Mord-erg.- Hr- i'rruzn dais-{mtg Fun macaw cf Fem Puisc: Tiaraalir. PMM Rith Harms! Lei": Nervnai Fihlni Right: Norma; Left. ?r?w?Lufun?i simmer} teat: Right Norma. Left f'?nrn?m CURRENT CORDIWON REVIEW trend .a-e?dmi with cedar?. mama-.- Description "gvg?m?w (Inwi?mhz-f. 'y-?c?lf?a-afaul :TL-mpiimt1w?. .?ifl Additiana! info f'duQ-r-Ev CibCY?ifj,? 1 HTH ?1'35 - walnut-mam) "with?? nan-1?} Pix-art i'm?iun?: r. Hoar? {Hr-ease- Faihm? {hugging Addi?: .1513 m" 5mm?? than 5. W?f?k? age and gaugier?; [Nd and unrpr?m'knn?. Eur am?: llizhiag :s?w m?c?ri'? a?uil gym; ?gnaw-rt and $.55 my. ewe-.1 and Jurernn'k. {w ASSESSMENT CURRENT CQNDITION PLAN Mods, Monimr Giet Lab Refer-m} Prmbiem Commem .5 Condiment-2cm fur faljrag I aw hark main heart disease of nature LDr-uriur?y' artery mu: um; pct-"a a Chm-am? atrirl (mam: obstructive puimom r; digs-me. ?wreaked macs: iicidcmia. . Case 7:17-cv-07515-KMK Document 12 Filed 08/04/20 Page 64 of 64 ‫ ﺍ‬1::،‫ﺍ‬.‫ﺍ‬.»‌>.»‌٠ ‫ ﺃ‬1،´:1‫ﺍ‬:‫ ﻷ‬:>