On May 1, 2017, the United States intervened in a False Claims Act lawsuit against UnitedHealth Group, Inc. and filed a complaint alleging that UnitedHealth knowingly disregarded information about the medical conditions of beneficiaries in its largest Medicare Advantage Plan, which increased the risk adjustment payments it received from Medicare.  UnitedHealth, the nation’s largest Medicare Advantage Organization, receives monthly, per-beneficiary payments from Medicare that are significantly influenced by the health status of each beneficiary.  The United States’ complaint alleges that UnitedHealth funded chart reviews to increase the risk adjustment payments from Medicare, but then ignored information about invalid diagnoses from those chart reviews to avoid repaying Medicare funds to which it was not entitled.  The whistleblower lawsuit was initially filed under the False Claims Act by former employee of Senior Care Action Network Health Plan James Swoben, who is also a risk adjustment industry consultant.  On May 16, 2017, the United States intervened in a separate but related False Claims Act “whistleblower” lawsuit against UnitedHealth.  In addition to alleging that UnitedHealth ignored information from chart reviews to obtain inflated risk adjustment payments in a scheme similar to the one discussed above, the second complaint further alleges that UnitedHealth ignored information that its health-care providers were providing invalid diagnoses because of their financial arrangement with UnitedHealth.  These providers, the government contends, were motivated to provide invalid diagnoses because their pay was tied to the amount provided to UnitedHealth through Medicare.  The complaint alleges that UnitedHealth confirmed that these diagnoses were invalid, but did not take further action to identify other invalid diagnoses or repay the Medicare funds provided based on these diagnoses.  This False Claims whistleblower suit was filed initially by Benjamin Poehling, who was the former finance director for the group that managed UnitedHealth’s Medicare Advantage Plans.  United States ex rel. Swoben v. Secure Horizons et al., CV09-5013 (C.D. Cal.); United States of America ex rel. Poehling v. UnitedHealth Group, Inc., CV16-8697 (C.D. Cal.).

DOJ Press Release

DOJ Press Release