UnitedHealth Group, a large American health insurer, has been recommended positively by a special master appointed by the court in a high-profile case of Medicare fraud filed by the U.S. Department of Justice (DOJ). The case, filed in 2016, accused UnitedHealth of submitting false diagnoses to increase payments from the Medicare Advantage program. The report of the special master could allow the dismissal of the DOJ case against the company.
Background of the Case
The complaint of the DOJ alleged that UnitedHealth submitted knowingly false diagnosis codes for Medicare Advantage plan patients. Medicare Advantage, a plan under which private insurers provide Medicare benefits, reimburses insurers based on the health of their members, with sicker patients receiving more money. The government accused UnitedHealth of exaggerating patients’ conditions in order to receive more reimbursements, which amount to billions of dollars in overpayments.
Special Master’s Findings
Special Master Suzanne Segal examined the evidence and concluded that the DOJ did not have enough evidence to back its claims of fraud against UnitedHealth. She observed that the government case mostly depended on differences between diagnoses reported by physicians and later reviewed by UnitedHealth’s coders. Segal concluded that these differences were not evidence of fraud, as there “simply was no fraud.”
UnitedHealth’s Response
Following the special master’s suggestion, UnitedHealth was pleased with the outcome. The firm condemned the lengthy investigation by the DOJ, claiming that after over a decade, there was no proof to back allegations of overpayment or misconduct.
Implications for the Healthcare Industry
This advancement carries strong implications for the healthcare industry, with the Medicare Advantage program in mind. The case has identified complications with the correct coding and reporting of patient diagnoses that affect payment levels. An upholding for UnitedHealth has the potential to alter insurers’ documentation of patients as well as how the government monitors and assures compliance with the program.
Next Steps
The special master’s suggestion is not a final decision. U.S. District Judge Fernando Olguin will consider the report and determine if he will have it adopted. If it is adopted, the DOJ’s allegations against UnitedHealth will be dismissed, closing the case. So far, the DOJ has not replied to the special master’s suggestion or indicated whether it will challenge the report.
The positive endorsement of UnitedHealth in this high-profile Medicare fraud case highlights the nuance surrounding healthcare billing and regulatory compliance. The result of this case could have a precedent-setting effect on how such accusations are handled in the future, potentially affecting the business of other insurers that operate in government-financed healthcare programs.
