A whistleblower lawsuit alleges that UnitedHealth Group and health plans that hired a subsidiary of the Minnetonka-based insurer have submitted false information about patient conditions to boost payment rates from the federal Medicare program.
If true, the scheme could have generated hundreds of millions, if not billions, of dollars in government overpayments to health plans, according to a lawsuit unsealed this week after the U.S. Department of Justice said it would join the case.
Matthew Burns, a spokesman for UnitedHealth, denied the allegations, saying in a statement: "We reject these more than 5-year-old claims and will contest them vigorously."
The whistleblower case focuses on "Medicare Advantage" health plans that are operated by private insurance companies to manage care for people covered by the government insurance program.
Medicare health plans make payments to doctors and hospitals when enrollees use services. The government, in turn, pays the health plans a set per-member, per-month rate that's meant to cover health care costs plus the insurance company's overhead.
At issue in the lawsuit are the government payments, which are adjusted upward for insurers that happen to cover patients with more costly health problems. Rules for this "risk adjustment" have been controversial in the past, with UnitedHealth suing the federal government in January 2016 over a change in guidance on how to assess the health status of enrollees.
The lawsuit that the feds joined alleges that insurers boosted risk adjustment claims by submitting forms for diagnoses that health plan members didn't have or for which members weren't treated in the relevant year. Insurers also claimed that members were treated for more serious conditions than they actually had, according to the lawsuit.
Finally, health plans refused to correct claims submitted to the government, the lawsuit says, and reimburse Medicare.