US government sues UnitedHealth again for mischarging Medicare Advantage

[nitpicker]

https://www.rawstory.com/2017/05/us-government-sues-unitedhealth-again-for-mischarging-medicare-advantage/

US government sues UnitedHealth again for mischarging Medicare Advantage

Reuters
16 May 2017 at 23:29 ET


The U.S. Justice Department for the second time in a month sued UnitedHealth Group Inc on Tuesday, accusing the nation’s largest health insurer of obtaining over $1 billion from Medicare to which it was not entitled. The complaint, filed in federal court in Los Angeles, came after the Justice Department brought a separate but similar case against UnitedHealth. In both cases, the government intervened in whistleblower lawsuits against UnitedHealth.

The latest complaint came after the Justice Department intervened in a lawsuit brought by former UnitedHealth executive Benjamin Poehling, whose whistleblower case was filed under seal in 2011.
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In the lawsuit, the Justice Department alleged that UnitedHealth obtained inflated risk adjustment payments based on untruthful and inaccurate information about the health status of patients enrolled in its Medicare Advantage plans. The lawsuit said UnitedHealth’s conduct damaged the Medicare program by over $1.14 billion from 2011 to 2014. The Justice Department said it is seeking triple damages under the False Claims Act as well as penalties.

Poehling filed his lawsuit under the False Claims Act, which allows whistleblowers to sue companies on the government’s behalf to recover taxpayer money paid out based on fraudulent claims. If successful, whistleblowers receive a percentage of the recovery. A government decision to intervene is typically a major boost to such cases.

Poehling also sued other insurers, claiming that they along with UnitedHealth had defrauded the United States of hundreds of millions – and likely billions – of dollars through claims for payments from Medicare for the elderly. While the Justice Department has not pursued claims against other companies, in March it said it was investigating Centene Corp’s Health Net Inc, Aetna Inc, Cigna Corp’s Bravo Health Inc and Humana Inc.
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[nitpicker]

1. From the DoJ PR

https://www.justice.gov/opa/pr/united-states-intervenes-second-false-claims-act-lawsuit-alleging-unitedhealth-group-inc

(snip)
UHG 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. 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 diagnosis that receives from treating physicians and subsequently submits to Medicare for each beneficiary.

The complaint filed today by the United States alleges that UHG knowingly disregarded information about beneficiaries’ medical conditions, which increased the risk adjustment payments UHG received from Medicare. In particular, the lawsuit contends that, for many years, UHG conducted a national Chart Review Program designed to identify additional diagnoses not reported by treating physicians that would increase UHG’s risk adjustment payments. However, UHG 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, UHG avoided repaying Medicare monies to which it was not entitled.

The complaint also alleges that UHG ignored information about invalid diagnoses from health care providers with financial incentives to furnish such diagnoses. These providers received payments from UHG tied to the amount of payments that UHG received from Medicare, and thus benefitted financially from any increase in Medicare payments resulting from the diagnoses they provided. UHG 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. UHG’s own reviews of these providers’ medical records confirmed that the providers were reporting invalid diagnoses. But upon obtaining such evidence, UHG knowingly avoided further efforts to identify invalid diagnoses from these providers and repay Medicare monies to which neither it nor these providers were entitled.
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[Delphinus]

2. Wow!

I need to share this information with some healthcare advocates of mine ... not sure I've read anything about this.