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U.S. Intervenes in ‘Whistleblower’ Case Alleging UnitedHealth Group Mischarged Medicare Advantage and Prescription Drug Programs

Posted by Fay Arfa | May 03, 2017 | 0 Comments

LOS ANGELES – The United States has intervened and filed a complaint in a lawsuit against UnitedHealth Group Inc. that alleges UnitedHealth obtained inflated risk adjustment payments based on untruthful and inaccurate information about the health status of beneficiaries enrolled in its largest Medicare Advantage Plan, UHC of California.

The civil complaint filed yesterday afternoon follows the government's intervention in February in United State ex rel. Poehling v. UnitedHealth Group. Inc., a related case in Los Angeles that also alleges that UnitedHealth defrauded the Medicare Program. The government is scheduled to file a complaint in the Poehling matter no later than May 16.

UnitedHealth is the nation's largest Medicare Advantage Organization, 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. UnitedHealth 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 UnitedHealth knowingly disregarded information about beneficiaries' medical conditions, which increased the payments UnitedHealth received from Medicare. In particular, the lawsuit contends that UnitedHealth funded chart reviews conducted by HealthCare Partners, one of the largest providers of services to UnitedHealth beneficiaries in California, to increase the risk adjustment payments received from the Medicare Program for beneficiaries under the care of HealthCare Partners. However, UnitedHealth allegedly ignored information from these chart reviews about invalid diagnoses and thus avoided repaying Medicare monies to which it was not entitled.

“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 “whistleblower” 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 case is United States ex rel. Swoben v. Secure Horizons, et al., CV09-5013. 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 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.

This matter was investigated by the United States Attorney's Office in Los Angeles, the Civil Division's Commercial Litigation Branch, the United States Attorney's Office for the Western District of New York, and the U.S. Department of Health and Human Services' Office of Inspector General.

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

The government's intervention in this matter illustrates the government's emphasis on combating healthcare fraud. 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).

USAO – California, Central Updated May 2, 2017

Central District of California DOJ / 17-090 / May 02, 2017

About the Author

Fay Arfa

Fay Arfa has the distinction of being Certified as a Specialist in two separate areas of law – Criminal Law as well as Appellate Law – by the California State Bar, Board of Specialization. The National Board of Trial Advocacy has also awarded her a board Certification in Criminal Trial Advocacy. ...


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