UnitedHealth asks judge to dismiss Medicare fraud case

gavel and books
In 2016, UnitedHealth filed a lawsuit that alleges CMS' overpayment rule puts an unfair burden on Medicare Advantage health plans.

Having successfully beaten one fraud case brought against it by the federal government, UnitedHealth is asking a federal judge to dismiss a similar case.

In a motion (PDF) filed last Friday, the insurer argues that the court should throw out the Department of Justice’s amended complaint, which accuses UnitedHealth of artificially inflating its Medicare Advantage risk scores in a bid to maximize government reimbursement.

The DOJ first filed its False Claims Act case against the insurer in February, joining a whistleblower suit brought by former UnitedHealth employee Benjamin Poehling. In March, the agency intervened in another suit concerning UnitedHealth’s MA risk adjustment practices, which was brought by whistleblower James Swoben.

RELATED: Whistleblower speaks out about Medicare Advantage fraud claims against UnitedHealth

In October, though, a federal judge dismissed the Swoben case, saying that it failed to prove that the Centers for Medicare & Medicaid Services would not have made the MA payments to UnitedHealth had it been aware of the practices alleged in the lawsuit. Later that month, the DOJ declined to file an amended complaint, essentially abandoning the case.

Now UnitedHealth wants the DOJ to also abandon the Poehling case. The insurer contends that the government’s amended complaint—which it filed after the Swoben ruling—“includes more than a hundred new paragraphs of allegations” but still fails to allege that CMS would have refused to make risk adjustment payments to UnitedHealth if it had known about its coding practices.

“Put simply, the amended complaint lacks the essential allegations because DOJ knows the true facts: namely, that CMS has been aware of errors in coding data submitted by United (and every MA insurer) and has never once sought to withhold payment,” the motion said.

UnitedHealth filed a lawsuit against the federal government back in 2016 that alleges CMS puts an unfair burden on MA health plans with its requirements to report and return overpayments. In fact, the suit said, CMS’ rules result in systemic underpayment to MA plans. In October—following the dismissal of the Swoben suit—UnitedHealth filed a motion in its case against CMS asking the court to issue a summary judgement and throw out the offending overpayment rule.

But last week, the government filed a motion in opposition to the that request, arguing that its overpayment rule is reasonable and that “the administrative record does not support United’s claim that the risk adjustment model systematically underpays insurers.”

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