Tags: Healthcare Insurance, Legal Case, Medicare Advantage, Fraud Investigation
Court Rules in Favor of UnitedHealth
The U.S. Department of Justice (DOJ) faced a major setback in its long-running lawsuit against UnitedHealth Group over alleged Medicare Advantage overpayments. Special Master Suzanne Segal ruled that the government failed to provide sufficient evidence to support its claim that the health insurer exaggerated patient conditions to collect more than $2 billion in improper payments. She recommended granting UnitedHealth’s motion to dismiss the case, which will be presented to a federal judge. The government has two weeks to appeal.
DOJ’s Allegations Against UnitedHealth
The case was originally filed in 2011 by whistleblower Benjamin Poehling, a former UnitedHealth employee, and was taken over by the DOJ in 2017. The government alleged that UnitedHealth received over $7.2 billion from Medicare between 2009 and 2016 by reviewing patient records, adding extra diagnoses, and inflating medical billing codes. The DOJ claimed that if unsupported codes had been removed, Medicare would have paid the company $2.1 billion less.
Additionally, the DOJ accused UnitedHealth of ignoring overcharges that could have reduced billing amounts. However, Segal determined that the case relied on speculation and assumptions rather than concrete evidence, undermining the government’s claims.
UnitedHealth’s Defense and Court Findings
UnitedHealth denied any wrongdoing, stating that after years of litigation, the special master found no evidence supporting the DOJ’s claims of overpayments.
Segal noted that UnitedHealth executives had disclosed their chart review practices to the Centers for Medicare & Medicaid Services (CMS) during a 2014 meeting. CMS had considered restricting such practices but ultimately decided against new regulations after strong industry opposition. Segal stated that UnitedHealth’s transparency in discussing these reviews contradicted the DOJ’s claims that the company concealed its actions.
Furthermore, audits conducted by CMS found that approximately 89% of UnitedHealth’s billing codes were supported by medical records, which weakened the government’s argument of widespread overbilling. Segal emphasized that after more than a decade of investigation, the government had ample opportunity to gather supporting evidence but failed to do so.
Ongoing Scrutiny of Medicare Advantage
Despite this legal victory, UnitedHealth remains under scrutiny, as the DOJ continues to investigate its Medicare Advantage coding practices. The Medicare Advantage program has seen rapid growth in recent years, enrolling approximately 33 million members, which accounts for more than half of all Medicare beneficiaries.
The industry has been the subject of multiple whistleblower lawsuits and government audits, with concerns over excessive costs to taxpayers. Recently, Senate Judiciary Committee Chair Chuck Grassley called on UnitedHealth to provide explanations regarding its billing practices, indicating that regulatory and legal scrutiny of the company’s operations will likely continue.
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