Medicare Advantage Fraud Lawsuit
The United States has joined a lawsuit brought by whistleblowers under the False Claims Act accusing UnitedHealth Group of bilking Medicare by fraudulently boosting payments through the inflation of plan members’ risk scores under Medicare Advantage. In other words, UnitedHealth told the United States that patients were sicker than they were and collected more money from the government as a result. This is the first major government enforcement action unsealed under Attorney General Jeff Sessions and the New York Times called it a case of fraud that likely implicated “billions” of dollars in Medicare payments.
The UnitedHealth lawsuit centers around the risk score adjustment for UnitedHealth’s Medicare Advantage plan. Medicare Advantage plans are a popular opt-in alternate to Medicare run by private insurers under Medicare Part C. The insurer is paid by the government based on the level of sickness of their patients – the risk score. If patients are misclassified, the company can engage in a risk adjustment process.
The lawsuit claims the government paid for the treatment of beneficiaries based on:
- diagnoses patients did not have;
- more severe diagnoses than the patient had;
- previous conditions not currently under treatment; and/or
- diagnoses that did not meet the standard for adjusting the patient’s risk score.
Among the specific policies contributing to the fraud identified in the complaint are:
- The company employed coding specialists to mine patient records and requested higher government payments without an in-person evaluation of the patient’s conditions.
- The company created targets for employees to increase risk scores by defined percentages. They did not judge employees by the accuracy of their risk adjustment submissions.
- The company ignored information that that they were being overpaid for patient care. The company only attempted to increase risk scores without looking for patients where they were receiving too much money.
The decision to join the whistleblower lawsuit was made by President Trump’s administration. Although the President is planning to streamline business regulations, the rising cost of healthcare is one area where he has promised to confront business. The government’s decision to lead the lawsuit appears to be confirmation the Trump Administration will continue President Obama’s legacy of tackling health care fraud.
The media has published information about government investigations in this area for a few years now. Based on these reports, there may be other sealed cases against insurance companies running Medicare Advantage plans. There may still be potential lawsuits for other whistleblowers to bring as all companies engaged in these practices may not have had a False Claims Act lawsuit filed against them.
What are some medicare fraud and abuse examples?
Medicare fraud and abuse refer to illegal activities that involve deceit or misrepresentation in order to obtain improper payments from the Medicare program. Here are some types of Medicare fraud
Billing for services not provided
Healthcare providers may submit claims for services or procedures that were never actually performed. This could involve submitting fabricated patient records or billing for services that are not medically necessary.
This occurs when providers bill for services that were not rendered to actual patients. They may use stolen or fraudulent patient information to submit claims for fictitious individuals.
Providers may offer or receive illegal kickbacks in exchange for patient referrals or the prescribing of certain medications or medical equipment. These kickbacks can distort medical decision-making and inflate healthcare costs.
Upcoding involves billing for a more expensive service or procedure than what was actually performed. For example, a healthcare provider might bill for a complex medical procedure when a less expensive one was performed.
Medicare typically pays for a bundle of services under a single billing code. Unbundling involves billing separately for individual components of a bundled service to maximize reimbursement. This is often done intentionally to obtain higher payments.
Fraudsters may steal the personal information of Medicare beneficiaries and use it to submit false claims. They may create fraudulent medical businesses or pose as healthcare providers to bill Medicare for services never provided.
Prescription drug fraud
This can involve activities such as prescribing unnecessary medications, overcharging for prescriptions, or filling prescriptions that were obtained with false information.
These are just a few examples of the types of fraud and abuse that can occur in the Medicare system. It’s important to note that these activities are illegal and can result in significant financial losses for the Medicare program and taxpayers, as well as compromised patient care. Efforts are continually being made to detect and prevent Medicare fraud and abuse through increased monitoring, data analytics, and enforcement actions.