DOJ joins second Medicare Advantage fraud lawsuit against UnitedHealth over risk adjustment practices

The Department of Justice has joined another lawsuit that accuses UnitedHealth of fraudulently inflating its Medicare Advantage risk scores to maximize reimbursement.

A court document (PDF) filed Friday indicated that the DOJ will intervene in a suit that whistleblower James Swoben brought against UnitedHealth, which accuses it of conducting biased retrospective reviews of medical records aimed at boosting its MA reimbursement.

HealthCare Partners is also named in the fourth amended version of Swoben’s suit, which he first filed in 2009, though the DOJ is not currently intervening against the physician group and its affiliates.

In the Medicare Advantage program, higher risk scores—which are calculated by the level of services each beneficiary requires—mean greater payments from the government, creating an incentive for plans to upcode. Yet the Centers for Medicare & Medicaid Services has been aware since 2008 that some MA plans have been collecting billions of dollars in overpayments, and has been slow to conduct audits to recoup that money, according to the Center for Public Integrity.

Meanwhile, the DOJ is also seeking to consolidate the Swoben case with another lawsuit brought by whistleblower Benjamin Poehling, according to a court document (PDF) filed Monday. In that suit, Poehling accused 15 insurers of False Claims Act violations related to MA risk scores, but so far the government is intervening only in the cases involving UnitedHealth and its subsidiary, WellMed Medical Management.

Swoben’s attorney, William K. Hanagami, told Kaiser Health News that he expected the combined cases could result in damages topping $1 billion.

But UnitedHealth is “confident we complied with program rules,” spokesman Matt Burns said in a statement to FierceHealthcare. “Litigating against Medicare Advantage plans to create new rules through the courts will not fix widely acknowledged government policy shortcomings or help Medicare Advantage members,” he added.

Independently of the Poehling case that it’s joining against United, the DOJ is also investigating Aetna, Humana, Health Net and a division of Cigna called Bravo Health, a recent court filing revealed.

And that is hardly the only whistleblower case that has been filed against MA plans, with a 2015 report indicating at least six have been filed across the country.