$1B Medicare Advantage fraud case against UnitedHealth can proceed

The U.S. Department of Justice (DOJ) can move forward with a lawsuit alleging UnitedHealth Group wrongly collected more than $1 billion through Medicare Advantage by finding conditions to increase a patient’s risk adjustment payment from CMS.

According to Reuters, some of the DOJ’s claims related to false attestation of the data were dismissed, but unlike a separate Medicare Advantage lawsuit against UnitedHealth, a federal judge didn’t dismiss the entire case.

This case was first brought to court by former UnitedHealth executive Benjamin Poehling, who said he monitored the data-mining projects looking for additional diagnoses which could boost MA payments to UnitedHealth. He further claimed his team was given bonuses for hitting revenue targets—not improving patient outcomes or identifying conditions which wouldn’t increase risk scores or reimbursement. If the suit is successful, Poehling would be entitled to part of the money recovered from UnitedHealth.

The insurer has continued to deny the allegations.

“We reject the government’s remaining claims and will continue to aggressively contest them,” a UnitedHealth Group spokesperson said in a statement to the Minneapolis Star-Tribune.

More of the lawsuit could be dismissed, however. The ruling by U.S. District Judge Michael Fitzgerald said three of the six claims would be removed from the lawsuit unless the DOJ amends its complaints by Feb. 26.