Justice Department Joins Medicare Advantage $1B Fraud Lawsuit Against UnitedHealth

By Shelby Livingston, Modern Healthcare.

The U.S. Justice Department has joined a whistle-blower lawsuit claiming that UnitedHealth Group and affiliated health plans have been gaming the Medicare program and fraudulently collecting millions of dollars by claiming patients were sicker than they really were.

The lawsuit, initially brought in 2011 and unsealed Thursday after a five-year investigation by the Justice Department, alleges that Minnetonka, Minn.-based UnitedHealth has inflated its plan members’ risk scores since at least 2006 in order to boost payments under Medicare Advantage’s risk-adjustment program.

UnitedHealth, the nation’s largest Medicare Advantage insurer, allegedly collected payments from false claims that it treated patients for conditions they didn’t have, for more severe conditions than they had, conditions that had already been treated, or diagnoses that didn’t meet the requirements for risk adjustment, according to the complaint.

The lawsuit claims that in 2010, UnitedHealth planned to increase operating income by $100 million through “Project 7,” which was the company’s codeword for initiatives to increase risk-adjustment payments.

 February 16, 2017

Editor: Although the publication date of an article may not be current the information is still valid.

Private Health Insurers Involved in Massive Fraud Against the American Public.


A certain percentage of medical service providers file fraudulent claims with private health insurers by overcharging, double billing, charging for additional services or issuing false claims. The reasons that they do so are numerous and varied, not the least of which is that private insurers, in order to increase their profits, pay providers the least amount possible for their medical services and take an unreasonably long time to pay, thereby fostering an atmosphere of desperation and deceit as providers struggle to survive, and some take advantage.

Insurers are aware of the deceit but fail to act against providers because: 1) they know that they take unfair advantage of providers by reimbursing at low rates and taking an extended period of time to pay; 2) establishing provider networks is costly and they do not wish to eliminate providers as long as they bring profits; and, 3) there is no net benefit to insurers to act against providers when they can simply pass the cost on to consumers by increasing premiums or reducing benefits, or reducing reimbursements to providers even more.

Health insurers are co-conspirators in a massive fraud against the American public. Medical fraud is a significant factor in the unreasonably high percentage of our GDP attributed to healthcare spending (17.2% in 2012, the most of any industrialized nation and 2 1/2 times the OECD average) and a drag on our economy. Medical bills remain the number one cause of bankruptcy in our country.

March 1, 2014

Editor: Although the publication date of an article may not be current the information is still valid.


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