The United States has joined a lawsuit brought by whistleblowers under the False Claims Act accusing UnitedHealth Group of bilking Medicare by fraudulently boosting payments through the inflation of plan members’ risk scores under Medicare Advantage. In other words, UnitedHealth told the United States that patients were sicker than they were and collected more money from the government as a result. This is the first major government enforcement action unsealed under Attorney General Jeff Sessions and the New York Times called it a case of fraud that likely implicated “billions” of dollars in Medicare payments.
The UnitedHealth lawsuit centers around the risk score adjustment for UnitedHealth’s Medicare Advantage plan. Medicare Advantage plans are a popular opt-in alternate to Medicare run by private insurers under Medicare Part C. The insurer is paid by the government based on the level of sickness of their patients – the risk score. If patients are misclassified, the company can engage in a risk adjustment process.
The lawsuit claims the government paid for the treatment of beneficiaries based on:
- diagnoses patients did not have;
- more severe diagnoses than the patient had;
- previous conditions not currently under treatment; and/or
- diagnoses that did not meet the standard for adjusting the patient’s risk score.
Among the specific policies contributing to the fraud identified in the complaint are:
- The company employed coding specialists to mine patient records and requested higher government payments without an in-person evaluation of the patient’s conditions.
- The company created targets for employees to increase risk scores by defined percentages. They did not judge employees by the accuracy of their risk adjustment submissions.
- The company ignored information that that they were being overpaid for patient care. The company only attempted to increase risk scores without looking for patients where they were receiving too much money.
The decision to join the whistleblower lawsuit was made by President Trump’s administration. Although the President is planning to streamline business regulations, the rising cost of healthcare is one area where he has promised to confront business. The government’s decision to lead the lawsuit appears to be confirmation the Trump Administration will continue President Obama’s legacy of tackling health care fraud.
The media has published information about government investigations in this area for a few years now. Based on these reports, there may be other sealed cases against insurance companies running Medicare Advantage plans. There may still be potential lawsuits for other whistleblowers to bring as all companies engaged in these practices may not have had a False Claims Act lawsuit filed against them.