DOJ Sues UnitedHealth over Alleged $1B Medicare Fraud
UnitedHealth has been sued again for alleged Medicare Advantage fraud, which netted the payer more than $1 billion in payments.
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- The Department of Justice is suing UnitedHealth for alleged Medicare Advantage fraud in a civil case. The complaint, filed in the Western District court, is “for monies unlawfully obtained or retained from the insurers Medicare Advantage (MA) plans.”
“This case involves conduct by United – the nation’s largest owner of MA Organizations – to improperly obtain or avoid returning payments under the Medicare Advantage Program that it was not entitled to receive,” states the lawsuit.
The insurer is alleged to have used “gaming” to report Medicare Advantage beneficiaries as sicker than they were in order to bill the federal government for more money.
This Justice Department suit adds to a 2009 whistleblower lawsuit by James Swoben, also for alleged “gaming.”
The suit further alleges UnitedHealth of orchestrating a long-term scheme to influence providers and accuses the company of having altered hundreds of thousands of diagnosis codes resulting in higher amounts paid to the company from Medicare.
It also alludes to the insurer’s involvement in risk adjustment schemes, and in knowingly reporting “skewed data,” for the purpose of collecting un-owed revenue, and in avoiding revenue owed.
UnitedHealth spokesman Matt Burns denied any wrongdoing by the company. “We are honored to serve millions of seniors through Medicare Advantage, proud of the access to quality health care we provided, and confident we complied with program rules,” he wrote in an email to the Center for Public Integrity.
Matt Burns also said that “litigating against Medicare Advantage plans to create new rules through the courts will not fix widely acknowledged government policy shortcomings or help Medicare Advantage members and is wrong.”
Medicare Advantage payments are determined by the risk score of individual enrollees. Patients are divided into two categories: high-risk patients with higher healthcare costs, and lower-risk patient, with less associated costs. To cover the high-risk patients, Medicare Advantage plans charge more for coverage.
Risk gaming occurs when payers inflate patient risk scores and request higher payments.
The practice of gaming, and the issue of Medicare and Medicare Advantage fraud, have been hot-topic issues for both parties in Washington, DC.
In a recent letter to CMS Acting Administrator Seema Verma, Chairman of the Senate Judiciary Committee, Charles Grassely (R-IA) asked CMS about its current steps to prevent fraudulent Medicare Advantage billing.
“CMS must aggressively use the tools at its disposal to ensure that it is efficiently identifying fraud and subsequently implementing timely and fair remedies,” wrote Grassely. “The use of these tools is all the more important as Medicare Advantage adds more patients and billions of dollars of taxpayer money is at stake.”
“By all accounts, risk score gaming is not going to go away,” Grassely stated.
With an aging population, member growth in Medicare Advantage plans is expected to expand significantly in coming years. This expansion could open the way for additional fraudulent billing, as noted by Grassely. To combat this the senator called for additional CMS audits.
“The use of these tools is all the more important as Medicare Advantage adds more patients and billions of dollars of taxpayer money is at stake,” Grassley said.