A whistleblower lawsuit alleges that UnitedHealth Group’s data analytics division helped the Minnetonka-based insurer and other health plans defraud the federal Medicare program by “upcoding” risk adjustment scores to boost payment rates.
A federal judge in California this week unsealed the lawsuit after the U.S. Department of Justice said it would join the case.
Matthew Stearns, a spokesman for United, said in a statement: “We reject these more than five-year-old claims and will contest them vigorously.”
When the initial lawsuit was filed in 2011, it named about a dozen health care companies. The government said it would move forward against claims against just two defendants — United and a Texas company called WellMed, which United acquired about five years ago.
The whistleblower case focuses on claims submitted by “Medicare Advantage” health plans that are operated by private insurance companies to manage care for people covered by the government program for people age 65 and older.
Through a subsidiary formerly known as Ingenix, and now called OptumInsight, United “engaged in systematic fraud by assisting and causing [Medicare Advantage] organizations … to submit fraudulent risk adjustment claims,” the lawsuit states. “Through this fraudulent scheme, defendants have defrauded the United States of hundreds of millions — and likely billions — of dollars.”
The lawsuit claims that insurers boosted risk scores by submitting claims for diagnoses that health plan members didn’t have, or for which members weren’t treated in the relevant year. Insurers also claimed that members were treated for more serious conditions than they actually had, according to the lawsuit.
In addition, insurers refused to correct claims submitted to the government, the lawsuit says, and reimburse Medicare.
Other health plans hired Ingenix for help with assessing risk scores, the lawsuit claims. In addition, UnitedHealthcare’s Medicare Advantage plans used the service, according to the complaint. It say United’s Medicare Advantage plans cover about 2.2 million people.
Stearns, the UnitedHealth Group spokesman, said his company is “honored to serve millions of seniors through Medicare Advantage, proud of the access to quality health care we provided, and confident we complied with the program rules.”
In whistleblower cases that allege false claims, lawsuits are filed by “relators” on behalf of the federal government. In the United case, the relator is Benjamin Poehling, a director of finance who started working for the company in Minnesota in 2004, according to the lawsuit.
False claim cases are filed to recover funds for the government, with relators receive a portion of any recoveries.
Twitter: @chrissnowbeck
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