Report: UnitedHealth under investigation by DOJ for Medicare Advantage upcoding

The U.S. Department of Justice (DOJ) is investigating potential illegal activity at UnitedHealth Group, related to the insurer’s billing practices, according to a report published Friday by the Wall Street Journal.

Per the outlet, UnitedHealth is being probed for upcoding Medicare Advantage claims. Specifically, the DOJ is looking into whether the insurer is responsible for billing the Centers for Medicare & Medicaid Services (CMS) for patient diagnoses not applicable to the actual care a patient will need, in an effort to boost monthly payments received through the program. 

For its coverage, the Wall Street Journal cites sources familiar with the case. According to reporters, the DOJ has spoken with providers about the alleged upcoding, which could have led to the insurer pocketing billions of extra reimbursement dollars. 

The Wall Street Journal also reported that the Department of Health and Human Services Office of Inspector General (OIG) is supporting the DOJ investigation. However, neither agency has released a statement. 

UnitedHealth quickly responded, issuing its own statement Friday morning, calling the claims made by the Wall Street Journal "misinformation" and adding that the outlet has a history of misleading the public about the Medicare Advantage program.

"We are not aware of the 'launch' of any 'new' activity as reported by the Journal," the company said. "We are aware, however, that the Journal has engaged in a year-long campaign to defend a legacy system that rewards volume over keeping patients healthy and addressing their underlying conditions." 

Last summer, reporters digging into billions of medical claim records found that insurers may be responsible for $50 billion in fraud related to Medicare Advantage, receiving payments for “hundreds of thousands of questionable diagnoses that triggered extra taxpayer-funded payments,” including for deadly illnesses that “people couldn’t possibly have.”

Those incidents are said to have occurred between 2019 and 2021. 

For more, read the full exclusive from the Wall Street Journal at the link below.