Whistleblower speaks out about Medicare Advantage fraud claims against UnitedHealth

Benjamin Poehling, a UnitedHealth executive-turned-whistleblower, says insurers have set up a “perfect scheme” to game the Medicare program and benefit their bottom lines.

The federal government calculates payments to Medicare Advantage plans using risk scores tied to the level of services each patient requires. The higher the risk scores, the higher the reimbursement.

That incentive, Poehling said in an interview with The New York Times, led his former employer and other companies like it to systematically bilk the system out of billions of dollars.

Poehling lays out his claims in a lawsuit he first filed in 2011. The Department of Justice said in February that it planned to join the suit, which increases the likelihood that government money will be recovered.

Although the complaint accused 15 insurers of fraud, the DOJ so far has said it plans to sue only UnitedHealth and its subsidiary, WellMed Medical Management. The NYT notes that the DOJ has until the end of today to file an official complaint against UnitedHealth.

In his interview with the NYT, Poehling describes the practices that he oversaw as UnitedHealth’s finance director, which he said involved mining patient data in a bid to make patients appear sicker than they were in order to inflate risk scores. That, in turn, increased government payments.

The scheme, Poehling said, was “not about delivering better care to members,” but rather, aimed at earning more revenue. “I came to the point where I just couldn’t participate in what they were asking me to do anymore,” he added.

UnitedHealth, however, denies the allegations against it.

“We are confident our company and our employees complied with the government’s Medicare Advantage program rules, and we have been transparent with CMS about our approach under its murky policies,” spokesman Matthew Burns wrote in an emailed statement. “We reject these claims and will contest them vigorously.”

The DOJ has also officially joined another whistleblower suit against UnitedHealth relating to its Medicare Advantage risk adjustment practices. The agency tried to consolidate that case with the Poehling case, but that motion was denied.

For its part, UnitedHealth has sued the government over a federal rule that requires Medicare Advantage plans to return overpayments within 60 days. A judge recently rejected the government’s attempt to dismiss that lawsuit, a decision that also might help UnitedHealth’s defense in the two whistleblower cases.