A practical example given was how the government would pay UnitedHealth $9,580 a year for enrolling a 76-year-old woman with diabetes and kidney failure as a standard payment. If, however, the company claimed that her diabetes had caused her kidney failure, the payment rose to $12,902—an additional $3,322. Such data manipulation could raise the government’s payments to UnitedHealth by nearly $3,000 per new diagnosis. Furthermore, the complaint alleges, the company did not bother looking for dangerous conditions like high blood pressure—because it did not raise the risk scores.
The suit also alleges that UnitedHealth knowingly disregarded information about beneficiaries’ medical conditions, which increased the risk adjustment payments the company received from Medicare. By ignoring this information, UnitedHealth avoided repaying Medicare monies to which it was not entitled, the suit claims. At least a third of all Americans who receive some form of Medicare have used the program, according to the statement. The action is the second such complaint to be lodged against UnitedHealth by the Department of Justice within the previous two weeks. The lawsuit was filed by Benjamin Poehling, the former finance director for the group that managed UnitedHealth’s Medicare Advantage Plans. It 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.
A spokesman for UnitedHealth disputed all the claims, and said that they were based on faulty interpretations of Medicare rules. “We reject these more than five-year-old claims and will contest them vigorously,” said the spokesman, Matthew A. Burns. He said the company served millions of Medicare Advantage members and was “proud of the access to quality health care we provided, and confident we complied with the program rules.” The amounts involved may be considerable, with some analysts estimating that improper Medicare Advantage payments might total at $10 billion a year or more. The Justice Department has said it is investigating four other Medicare Advantage insurers: Aetna, Humana, Health Net, and Cigna’s Bravo Health. The Government Accountability Office reported last year that the Centers for Medicare and Medicaid Services had identified $14.1 billion of overpayments to insurers in 2013 and did not have a clear plan for recovering the money. It also faulted the agency’s auditing methods.
Just last month, Senator Grassley wrote to Seema Verma, the administrator of the Centers for Medicare & Medicaid Services, complaining that the agencies had boasted about recovering $3.4 million in incorrect payments—but had admitted that the real losses it had suffered were in excess of $128 million. “The difference between the assessment and the actual recovery is striking and demands an explanation,” Sen. Grassley wrote. “Further, in light of the $70 billion in risk score overpayments between 2008–2013 reported by the Center for Public Integrity, CMS’s 2007 overpayment estimate of $128 million appears low and could very well be just the tip of the iceberg,” he continued. “By all accounts, risk score gaming is not going to go away. Therefore, CMS must aggressively use the tools at its disposal to ensure that it is efficiently identifying fraud and subsequently implementing timely and fair remedies. The use of these tools is all the more important as Medicare Advantage adds more patients and billions of dollars of taxpayer money is at stake.”
Sen. Grassley then requested the administrator to provide a full written report on what steps the agencies would be taking to monitor and correct matters.
See:
1. “U.S. Intervenes in Second ‘Whistleblower’ Lawsuit Alleging UnitedHealth Mischarged the Medicare Advantage and Prescription Drug Programs,” Department of Justice, U.S. Attorney’s Office, Central District of California, May 16, 2017.
https://www.justice.gov/usao-cdca/pr/us-intervenes-second-whistleblower-lawsuit-alleging-unitedhealth-mischarged-medicare
2. Letter from U.S. Senator Charles Grassley to Seema Verma, Administrator of the Centers for Medicare & Medicaid Services. April 17, 2017.
https://www.grassley.senate.gov/sites/default/files/constituents/2017-04-17%20CEG%20to%20CMS%20%28Risk%20Score%20Follow%20Up%29.pdf
