For the second time in two weeks, the United States has filed a complaint against UnitedHealth Group Inc. alleging that the company knowingly obtained inflated risk adjustment payments based on untruthful and inaccurate information about the health status of beneficiaries enrolled in UnitedHealth's Medicare Advantage Plans throughout the United States.
This second action followed the government's filing of a complaint earlier this month in United States ex rel. Swoben v. Secure Horizons, a related action that also alleged that UnitedHealth submitted false claims for payment to the Medicare Program.
United Health is the nation's largest Medicare Advantage Organization, with more than 50 Medicare Advantage and Drug Prescription plans providing healthcare services and prescription drug benefits to millions of Medicare beneficiaries throughout the United States. UnitedHealth receives a monthly “risk adjustment” payment from Medicare for each enrolled beneficiary. The risk adjustment payments are based, in significant part, on the health status of the beneficiary, which are reflected by the diagnosis that UnitedHealth receives from treating physicians and subsequently submits to Medicare for each beneficiary.
The new complaint alleged that UnitedHealth knowingly disregarded information about beneficiaries' medical conditions, which increased the risk adjustment payments the company received from Medicare. In particular, the lawsuit contended that, for many years, UnitedHealth conducted a national chart review program designed to identify additional diagnoses not reported by treating physicians that would increase its risk adjustment payments. However, UnitedHealth allegedly ignored information from these chart reviews showing that hundreds of thousands of diagnoses provided by treating physicians and submitted by it to Medicare were invalid and did not support the Medicare payments it had previously requested and obtained. By ignoring this information, UnitedHealth avoided repaying Medicare monies to which it was not entitled, the government alleged.
The complaint also alleged that UnitedHealth ignored information about invalid diagnoses from health care providers with financial incentives to furnish such diagnoses. These providers received payments from UnitedHealth tied to the amount of payments that UnitedHealth received from Medicare, and thus benefitted financially from any increase in Medicare payments resulting from the diagnoses they provided. UnitedHealth allegedly knew that its financial arrangements with these providers created a strong incentive for and increased the risk of these providers to report invalid diagnoses. UnitedHealth's own reviews of these providers' medical records confirmed that the providers were reporting invalid diagnoses, according to the complaint. But upon obtaining such evidence, UnitedHealth knowingly avoided further efforts to identify invalid diagnoses from these providers and repay Medicare monies to which neither it nor these providers were entitled, the government asserted.
“To ensure that the program remains viable for all beneficiaries, the Justice Department remains tireless in its pursuit of Medicare fraud perpetrated by healthcare providers and insurers,” said Acting U.S. Attorney Sandra R. Brown. “The primary goal of publicly funded healthcare programs like Medicare is to provide high-quality medical services to those in need – not to line the pockets of participants willing to abuse the system.”
The lawsuit was filed by Benjamin Poehling, the former finance director for the group that managed UnitedHealth's Medicare Advantage Plans. The lawsuit was filed under the qui tam provisions of the False Claims Act, which permit private parties to sue on behalf of the United States for false claims for government funds, and to receive a share of any recovery. The False Claims Act permits the government to intervene in such a lawsuit, as it has done, in part, in this case.
The case is captioned United States of America ex rel. Benjamin Poehling v. UnitedHealth Group, Inc., CV16-8697. The Poehling and Swoben cases are pending in the U.S. District Court for the Central District of California.
Steven A. Meyerowitz
Steven A. Meyerowitz, a Harvard Law School graduate, is the founder and president of Meyerowitz Communications Inc., a law firm marketing communications consulting company. He may be contacted at [email protected].