UnitedHealth Group and affiliated health plans have been defrauding the Medicare program by collecting millions of dollars by claiming patients were sicker than they really were.
The suit says 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, is the nation’s largest Medicare Advantage insurer. It 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.
In the Medicare Advantage program, the government pays private health plans monthly amounts for every member they cover, and those taxpayer-funded payments are adjusted based on how sick someone is.
Members with more chronic conditions have higher risk scores, and plans that cover them receive higher payments.
The suit makes allegations against Health Net, Arcadian Management Services, Tufts Associated Health Plans, Aetna, Blue Cross and Blue Shield plans in Florida and Michigan, Emblem Health, Humana, Wellcare Health Plans and others.
Jeffrey Newman represents whistleblowers but not those in these cases.