Justice Department Discloses False Claims Act Investigation into Multiple Payers

March 2017 ~

The U.S. Justice Department recently disclosed that there will be an investigation into four more major health insurers accused of defrauding Medicare by claiming patients were treated for conditions which no treatment was received as part of an ongoing whistleblower and False Claims Act lawsuit.

According to the Department, health insurance giants Health Net Inc., Aetna Inc., Cigna Corp’s, Bravo Health Inc. and Humana Inc. also face accusation of defrauding Medicare and will be included in the False Claims investigations.

The original lawsuit was brought against UnitedHealth Group in 2011 by a former finance manager for UnitedHealthcare Medicare and Retirement, the initial lawsuit (U.S. ex rel. Benjamin Poehling v. UnitedHealth Group Inc. et al, U.S. District Court, Central District of California, No. 16-cv-08697) claimed UnitedHealth misrepresented health status of beneficiaries with Medicare Advantage (MA) plans in order to receive higher reimbursement rates.

The Justice Department joined the Poehling v. UnitedHealth suit in February and at that time stated it was declining to pursue claims against other insurers named in the lawsuit besides UnitedHealth.

On March 14, the Department disclosed it had filed documents in the UnitedHealth v. Poehling case, saying that it could not decide whether to continue in the case until it completes its investigation into the other four insurers.

All five insurers are being accused of manipulating claim data in order to secure higher payments from CMS through risk adjustment and knowingly over-billing CMS by hundreds of millions of dollars over the span of several years.


Source(s): HealthcareDIVE; Reuters; The New York Times; The National Law Review; The United States Department Of Justice;