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United States Joins in Second False Claims Act Lawsuit against United Health Group Inc

Often, alleged healthcare fraud involves the proliferation of false and inaccurate information about patient health records. These kinds of activities endanger patient health and illegally enrich health care providers who are involved in such fraud. This was what the Justice Department alleged when last week it announced that it had filed a complaint against UnitedHealth Group Inc. (UHG) for the second time in two weeks. The government is alleging that UHG knowingly obtained inflated risk adjustment payments based on untruthful information about the health status of beneficiaries enrolled in UHG’s Medicare Advantage Plans. In a related action involving false claims submitted to Medicare, the government filed a complaint earlier this month in United States ex rel. Swoben v. Secure Horizons. “The Department of Justice’s pursuit of this matter illustrates its firm commitment to ensure the integrity of the Medicare Program, including those parts of the program that rely on the services of Medicare Advantage Organizations,” said Acting Assistant Attorney General Chad A. Readler of the Justice Department’s Civil Division.

UHG is the nation’s largest Medicare Advantage Organization. It receives a monthly “risk adjustment” payment from Medicare for each enrolled beneficiary. These adjustments are primarily based on the health status of the beneficiary which is reflected in the diagnosis the patient receives from physicians. The complaint filed last week alleges that UHG knowingly ignored information about the medical conditions of beneficiaries and this in turn increased the risk adjustment payments Medicare gave to UHG. Specifically, the lawsuit maintains that UHG conducted a program designed to identify diagnoses not reported by physicians that would increase its risk adjustment payments. However, UHG allegedly ignored information in this program that showed that thousands of diagnoses provided to Medicare were invalid and thus did not support payments UHG received. Thus, UHG avoided repaying Medicare monies they owed the program by ignoring this information.

Moreover, the complaint alleges that UHG ignored information about invalid diagnoses based on financial incentives. Health care providers received payments from UHG connected to the amount of payments that UHG received from Medicare. UHG allegedly knew that its financial arrangement with certain health care providers created an incentive for these providers to report invalid diagnoses. This fact was confirmed by UHG’s review of these providers’ medical records. UHG is then said to have ignored evidence identifying invalid diagnoses from these providers and thus avoided repaying Medicare monies that neither it nor these providers were entitled. “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 for the Central District of California. “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 UHG group. Poehling managed UHG’s Medicare Advantage Program and filed his lawsuit under the qui tam provisions of the False Claims Act. The qui tam provisions of the False Claims Act permit private parties to sue on behalf of the federal government and to then share in any subsequent recovery. The government intervened in this case as part of its ongoing effort to crack down on healthcare fraud. The False Claims Act is one tool that it uses to this end.

If you have chosen to disclose wrongdoing it is also advised that you contact a qui tam lawyer. A False claims act lawyer will be able to advise you on such matters and protect your rights. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement, can be reported to the Department of Health and Human Services, at 800-HHS-TIPS (800-447-8477).