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United Healthcare Group Faces Another False Claims Act Lawsuit

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  • Posted on: May 12 2017

The Justice Department has joined a whistleblower lawsuit against United Healthcare Group, Inc. (“UHG” or “United”) in connection with payments made to the company for its Medicare Advantage Plan. (Here.)

The suit claims the insurer obtained inflated risk-adjusted payments from the Medicare program by providing false and inaccurate information about the health risks of patients enrolled in UHG’s largest Medicare Advantage Plan, UHC of California. The original lawsuit was filed by James Swoben, a former employee of Senior Care Action Network (SCAN) Health Plan, under the qui tam provisions of the False Claims Act.

“The intervention of the United States in this matter illustrates our commitment to ensure the integrity of the Medicare Part C program,” said Acting Assistant Attorney General Chad A. Readler of the Justice Department’s Civil Division.

What is the Medicare Advantage Program?

The Medicare Advantage program is a privately run alternative to the government’s Medicare program for the elderly and disabled. Private insurers who participate in this program provide coverage in return for contractual monthly payments. Those payments are determined, in part, on patient-risk scores that are based on their medical conditions in the previous year. United is reportedly the nation’s largest Medicare Advantage organization, providing healthcare services and prescription drug benefits to millions of individuals across the country. Currently, about 30 percent of Medicare beneficiaries are enrolled in Medicare Advantage programs.

UHG False Claims

The suit claims that UHG disregarded information about patients’ medical conditions in order to increase the risk-adjusted premiums received from the Medicare program for beneficiaries under the care of a United service provider, Healthcare Partners (“HCP”). In particular, United allegedly funded chart reviews conducted by HCP, and ignored information from these reviews about invalid diagnoses. In short, UHG  received payments to which it was not entitled.

“Since 2005, UnitedHealth knew that many diagnosis codes that it submitted to the Medicare Program for risk adjustment were not supported and validated by the medical records of its enrolled beneficiaries,” according to the complaint.

This lawsuit comes on the heels of another qui tam action the Justice Department joined in February in which the government alleged United defrauded the Medicare program (United States of America ex rel. Benjamin Poehling v. UnitedHealth Group, Inc.). 

The False Claims Act allows whistle-blowers to file lawsuits against companies on behalf of the government and receive between ten and thirty percent of any recovery. If you know of a violation of the False Claims Act, you should speak with an experienced attorney who can help you understand and explore your options in blowing the whistle on fraud.

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