Feds probe Aetna, Humana, Health Net, Cigna division over Medicare Advantage risk scores

DOJ
Health Net, Aetna, Humana and Cigna’s Bravo Health are facing an investigation by the Department of Justice over their risk adjustment practices.

In addition to joining a whistleblower suit against UnitedHealth, the federal government is also investigating whether four major insurers submitted false claims that resulted in Medicare Advantage overpayments.

Court documents unsealed last month revealed the Department of Justice’s decision to intervene in the case against UnitedHealth, which accused the insurer of inflating patients’ risk scores to reap higher reimbursement. The DOJ declined to intervene, however, against the other 14 insurers named as defendants by whistleblower Benjamin Poehling in his original suit.

But in a court document (PDF) filed last week, the DOJ clarified that it “has been conducting, and continues to conduct, ongoing investigations” of four of those insurers—Health Net, Aetna, Humana and Cigna’s Bravo Health.

“Until those investigations are completed, the United States cannot reach a decision about the liability of these other defendants under the False Claims Act, with respect to the truthfulness of their claims to the Medicare Program for risk adjustment payments, the truthfulness of their risk adjustment attestations to the Medicare Program, or their possible improper avoidance of returning overpayments,” the document stated.

Therefore, the DOJ will continue to investigate the four insurers independent of the case it has joined against UnitedHealth.

In that case, Poehling—the former finance director for UnitedHealthcare Medicare and Retirement—accused his ex-employer of setting performance goals that encouraged employees to maximize revenue by increasing MA risk scores, but doing little to promote the accuracy of those risk adjustment submissions. The insurer always pushed providers to upcode, he claimed.

A spokesman for UnitedHealth, however, said in February that “we reject these more than five-year-old claims and will contest them vigorously.”

Another whistleblower suit, reopened last August, accused UnitedHealth, Aetna, WellPoint, Health Net and physician group HealthCare Partners of inflating MA risk scores to collect greater government payments.

In addition, the Center for Public Integrity previously pointed out that though the government knew about MA overpayments as far back as 2008, it opted to conduct fewer audits each year than it could have.