DOJ files official complaint in Medicare Advantage fraud case against UnitedHealth

In a newly filed complaint against UnitedHealth, the DOJ accuses the insurer of fraudulently inflating its Medicare Advantage risk scores. (Getty/BrianAJackson)

The Department of Justice has filed its official complaint in one of two whistleblower cases that it is joining against UnitedHealth concerning how the insurer conducts risk adjustment for its Medicare Advantage plans.

The DOJ first announced in late March that it planned to intervene in the case, which was initially filed in 2009 by whistleblower James Swoben. The complaint published this week lays out in greater detail the government’s accusations against UnitedHealth, which it says “knowingly disregarded information about beneficiaries’ medical conditions," which increased its payments from Medicare.

UnitedHealth, the complaint alleges, violated the False Claims Act by funding medical chart reviews conducted by the provider group HealthCare Partners in order to increase risk adjustment payments, but ignoring when those reviews uncovered invalid diagnoses in order to avoid returning overpayments.

“This action sends a warning that our office will continue to scrutinize and hold accountable Medicare Advantage insurers to safeguard the integrity of the Medicare program,” Acting U.S. Attorney Sandra R. Brown for the Central District of California said in the DOJ’s announcement.

UnitedHealth, however, said that it rejects the government’s claims against it and will “vigorously” contest them.

“We are confident our company and its leaders complied with Medicare Advantage program rules and were transparent with CMS about how we interpreted the government’s murky policies,” spokesman Matthew Burns wrote in an emailed statement.

The Swoben case is one of two whistleblower suits against UnitedHealth that the DOJ has announced it will join. The government plans to file its formal complaint in the other case, brought by Benjamin Poehling, no later than May 16. Recently, however, a federal judge denied the DOJ’s motion to consolidate the two cases.

UnitedHealth also scored a win when a judge ruled that it can move forward with its own lawsuit against the government that challenges a federal rule that requires Medicare Advantage plans to return overpayments within 60 days.

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