Tag:UnitedHealth Group
Profits Over Patients: The DOJ’s Fraud Investigation into UnitedHealth’s Medicare Practices
The Department of Justice (DOJ) has launched a civil fraud investigation into UnitedHealth’s Medicare billing practices, scrutinizing allegations that the company improperly inflated patient diagnoses to secure higher federal payments. While the investigation was publicly announced via the Wall Street Journal recently, it has been underway since 2024. This development follows the December 2024 death of UnitedHealth CEO Brian Thompson, which sparked renewed public discourse on the ethics of insurance companies. Many individuals came forward with stories of denied coverage for life-saving treatments, raising broader concerns about the practices of private insurers managing Medicare benefits.
Escobar’s Materiality Standard Shields Organizations from the Risk in Risk Adjustment Payments
Finance Director for UnitedHealth Group brought qui tam suit against UnitedHealth Group, Inc. alleging that the organization upcoded risk adjustment data resulting in increased payments (more than $1.14 billion) to UnitedHealth Group. The Department of Justice (DOJ) intervened in the case, yet UnitedHealth Group was successful in getting the primary False Claims Act Claims dismissed by arguing that the Centers for Medicare & Medicaid Services (CMS) would not have refused to make the adjustment payments had they known of the errors in the risk adjustment. The Escobar materiality standard helps clarify threshold level of risk to Managed Care Providers in attesting to their risk adjustment payments; the falsities must have had an impact on the respective payment.