The United States has intervened and filed a complaint in a lawsuit against UnitedHealth Group Inc. (UHG) that alleges UHG obtained inflated risk adjustment payments based on untruthful and inaccurate information about the health status of beneficiaries enrolled in UHG's largest Medicare Advantage Plan, UHC of California, the Justice Department announced today. Yesterday's action follows the government's intervention in February of this year in United State ex rel. Poehling v. UnitedHealth Group. Inc., a related lawsuit in the Central District of California that also alleges that UHG defrauded the Medicare Program. government is scheduled to file a complaint in that matter no later than May 16.

UHG is the nation's largest Medicare Advantage Organization (MAO), with more than 50 Medicare Advantage and Drug Prescription plans providing healthcare services and prescription drug benefits to millions of Medicare beneficiaries throughout the United States. receives a monthly payment from Medicare for each beneficiary that is based, in significant part, on the health status of the beneficiary.

The complaint filed yesterday by the United States alleges that UHG knowingly disregarded information about beneficiaries' medical conditions, which increased the payments UHG received from Medicare. In particular, the lawsuit contends that UHG funded chart reviews conducted by HealthCare Partners (HCP), one of the largest providers of services to UHG beneficiaries in California, to increase the risk adjustment payments received from the Medicare Program for beneficiaries under HCP's care. However, UHG allegedly ignored information from these chart reviews about invalid diagnoses and thus avoided repaying Medicare monies to which it was not entitled.

“The intervention of the United States in this matter illustrates our commitment to ensure the integrity of the Medicare Part C program,” said Acting Assistant Attorney General Chad A. Readler of the Justice Department's Civil Division.

“Medicare Advantage plans not only receive taxpayer-funded payments, but are intended for the health and welfare of the beneficiaries,” said Acting U.S. Attorney Sandra R. Brown for the Central District of California. “This action sends a warning that our office will continue to scrutinize and hold accountable Medicare Advantage insurers to safeguard the integrity of the Medicare program.”

The lawsuit was filed by James Swoben, a former employee of Senior Care Action Network (SCAN) Health Plan and a consultant to the risk adjustment industry. The lawsuit was filed under the qui tam provisions of the False Claims Act, which permit private parties to sue on behalf of the United States for false claims for government funds, and to receive a share of any recovery. The False Claims Act permits the government to intervene in such a lawsuit, as it has done, in part, in this case.

The government's intervention in this matter illustrates the government's emphasis on combating healthcare fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement, can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477).

This matter was investigated by the Civil Division's Commercial Litigation Branch, the U.S. Attorneys' Offices for the Western District of New York and the Central District of California, and the U.S. Department of Health and Human Services Office of Inspector General.

The claims asserted against UHG are allegations only, and there has been no determination of liability.

The case is captioned United States ex rel. Swoben v. Secure Horizons, et al., 09-5013. The Poehling complaint is captioned United States of America ex rel. Benjamin Poehling v. UnitedHealth Group, Inc., No. 16-08697. Both are pending in the U.S. District Court for the Central District of California.

Civil Division USAO – California, Central

Topic: False Claims Act     Healthcare Fraud Updated May 2, 2017

Central District of California DOJ / 17-481 / May 02, 2017