News: Whistleblower suit accuses UnitedHealthcare of improper billing

A False Claims Act lawsuit accuses UnitedHealthcare Group of a scheme which may have allowed its subsidiaries and other insurers to improperly overcharge Medicare by “hundreds of millions — and likely billions — of dollars,” The New York Times reported.

Benjamin Poehling finance director for UnitedHealthcare Medicare and Retirement (a Medicaid Advantage affiliate) originally made the accusations in 2011 claiming that senior leadership created “a corporate culture that demands and rewards financial success from its employees,” by asking them to ensure patients looked sicker than they really were. The sicker the patient, the higher the reimbursement. 

The complaint released this week by the Department of Justice (DOJ) enumerates the ways in which UnitedHealthcare engaged in “systematic fraud.” Two specific accusations include:

• “Upcoding” risk adjustment claims by submitting claims for diagnoses that the patient does not have or for which the patient was not treated in the relevant year, or by claiming that a patient was treated for a more serious condition than the member actually has
• Refusing to correct previously submitted risk adjustment claims when defendants discover, or in the exercise of reasonable care should discover, that those previously submitted claims were false

Medicare Advantage rules require in-person verification of clinical indicators on a regular basis by a qualified professional to qualify for risk adjustment factors.

An email message from Poehling’s division chief financial officer, Jerry Knutson, attached to the complaint urges staff members “to really go after the potential risk scoring that you have consistently indicated is out there.”

“Let’s turn on the gas!” Knutson’s email states. “What can we do to make sure we are being reimbursed fairly for the members and risk we take on more than what we are currently doing.”

The DOJ is currently investigating accusations against UnitedHealthcare and WellMed Medical Management (acquired by UnitedHealthcare in 2011). While the two suits are separate, the Justice Department reserves the right to combine them should they see fit.

Editor’s Note: To read a more in-depth look at the ongoing investigation, read the article by the New York Times, here. To read Poehling’s complete complaint, click here.