DOJ v. UnitedHealth

February 2017 ~

The Department of Justice (DOJ) has decided to move forward with legal action against two insurers – UnitedHealth and WellMed Medical Management – accused of erroneous coding and inflating policyholders’ risk scores to boost payments the insurer receives under Medicare Advantage’s (MA) risk adjustment program for more than a decade.

Former finance director for UnitedHealthcare Medicare and Retirement, Benjamin Poehling, initially filed the lawsuit in 2011. The original complaint accuses a total of 15 companies of overcharging for MA reimbursements and was previously kept sealed while claim investigations took place.

According to the complaint, made public on February 16, UnitedHealth allegedly:

  • received payments for covering beneficiaries’ treatments for conditions that beneficiaries did not have, did not meet the requirements for risk adjustment, had already been treated, or were more severe than what beneficiaries actually had;
  • in 2010 UnitedHealth planned to bolster its operating income by $100 million under “Project 7,” the alleged code word for the company’s efforts to increase its risk adjustment payments.
  • evaluated employees based on their ability to meet certain risk adjustment targets; and
  • coding specialists would search beneficiary records to identify those with possible long-term conditions and directly request the higher payment under the risk adjustment program.

DOJ asked the court to grant the department access to all documents involved in Poehling’s case, and it maintains the right to join Poehling’s allegations against the remaining companies at another time.

The DOJ has 90 days to file its own complaint.


Source(s): American Health Line, February 2017; The New York Times, February 2017; The Department of Justice, February 2017;