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Feds Sue UnitedHealth for Allegedly Defrauding Medicare Advantage of at Least $1B

Feds Sue UnitedHealth for Allegedly Defrauding Medicare Advantage of at Least $1B

Tuesday’s suit was the second false claims case against the insurer in two weeks.

For the second time this month, the federal government filed a complaint against UnitedHealth Group Inc., accusing the Minnetonka-based insurer of turning a blind eye to negative results that would impact its “risk adjustment” payments.
 
As a result, the feds claim UnitedHealth defrauded the Medicare alternative and private health plan system, known as Medicare Advantage, by at least $1 billion.
 
Every month, UnitedHealth receives money from Medicare Advantage as it submits risk scores, which are determined by a patient’s demographic factors and health status. Those payments would vary monthly as risk scores could change. Ultimately, healthy patients would receive less money than those needing to visit a hospital regularly for certain illnesses or conditions.
 
Since 2005, the government believes UnitedHealth inflated its risk scores by not updating hundreds of thousands of diagnosis that would have decreased its Medicare Advantage payments.
 
“As the nation’s largest Medicare Advantage Organization, UnitedHealth Group received substantial overpayments based upon untruthful and inaccurate information about the health status of those enrolled in its plans,” James P. Kennedy Jr., Acting U.S. Attorney for the Western District of New York, said in a statement.
 
In a report by the New York Times on Monday, UnitedHealth spokesman Matthew A. Burns said the company rejected the claims made in the case, which arose in 2011 by Benjamin Poehling, a Bloomington resident and former finance director at UnitedHealth.
 
“We are confident our company and our employees complied with the government’s Medicare Advantage program rules,” Burns said, “and we have been transparent with [the Centers for Medicare and Medicare Services] about our approach under its murky policies.”
 
The government first jumped on the case in late March when Poehling’s case was unsealed by a federal judge.
 
However, Poehling was not the first to sue UnitedHealth under these claims. California resident James Swoben filed a suit in 2009. That case was also taken over by the government and was the basis for the complaint placed against UnitedHealth two weeks before Tuesday’s case.
 
The government noted in a statement that the claims asserted against UnitedHealth are allegations only. To date, there has been no determination of liability on the company’s part.