Feds join whistleblower suit that accuses UnitedHealth of inflating Medicare Advantage risk scores

magnifying glass over word "whistleblower"
In recent years, several whistleblower complaints have surfaced accusing insurers of inflating MA risk scores. Image: Getty/Imilian

The Department of Justice has joined a whistleblower suit against UnitedHealth and one of its subsidiaries that accused them of engaging in a scheme to overcharge Medicare by inflating patients’ risk scores.

At the request (PDF) of the DOJ, a Federal District Court in Los Angeles recently unsealed a complaint (PDF) first filed in 2011 by Benjamin Poehling, who was the finance director for UnitedHealthcare Medicare and Retirement. The complaint alleged False Claims Act violations on the part of 15 insurers, but the DOJ is seeking to intervene only in the cases involving UnitedHealth and its subsidiary, WellMed Medical Management.

The Centers of Medicare & Medicaid Services pays Medicare Advantage plans using risk scores tied the level of services each patient requires. The higher the risk scores, the higher the reimbursement, which can create an incentive for insurers to upcode.

Such was the case at United when Poehling was there, his complaint alleged.

“At every level, United is driven by a corporate culture that demands and rewards financial success from its employees,” it said. That, Poehling claimed, led the company to evaluate employees based on their success at “maximizing revenue” by increasing risk scores, and to set specific goals for doing so.

However, “there were no similar performance goals for the overall accuracy of risk adjustment submissions,” the complaint noted.

Poehling also accused UnitedHealth of using coding specialists to find evidence of possible long-term conditions in patients’ records, then seeking higher reimbursement without undertaking the required in-person verification of the patients’ condition.

What’s more, “United encourages and provides incentives to its provider groups and risk adjustment vendors to upcode their claims data, and then uses that upcoded data to submit false and/or fraudulent risk adjustment claims to Medicare,” the complaint stated.

For its part, United denied the claims made against it. "We reject these more than five-year-old claims and will contest them vigorously," spokesman Matthew Burns said in an email. "We are 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."

However, this is not the first time that major insurers have faced allegations of risk score inflation.

Last August, a federal appeals court gave whistleblower James Swoben another chance to prove allegations that UnitedHealth, Aetna, WellPoint, Health Net and physician group HealthCare Partners conducted biased retrospective reviews of medical records already sent to CMS in order to increase reimbursement.

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And last March, a court unsealed a lawsuit against Humana that accused the insurer of encouraging physicians to elevate patient conditions in order to inflate risk scores, and ignoring one physician’s concerns about the practice.