Correction: In a prior version of this article, a Wisconsin UnitedHealth lawsuit was misidentified as pending.
- The U.S. Department of Justice has jettisoned much of a False Claims Act lawsuit alleging UnitedHealth Group used false billing data to jack up Medicare Advantage payments, Law360 reports.
- The DOJ’s decision came two weeks after a California federal judge dismissed allegations UnitedHealth infringed the FCA by knowingly attesting that the data were inaccurate. The department had until Monday to augment its allegations.
- In October, a California federal judge used the same argument in tossing a whistleblower lawsuit targeting UnitedHealth. That paved the way for the DOJ to amend its allegations against the insurer.
The October ruling came after UnitedHealth requested in July that the U.S. District Court for the Central District of California dismiss one of two qui tam lawsuits involving the FCA.
The company argued that the complaint failed to demonstrate it falsely attested to the data and that the government would have refused to pay UnitedHealth’s claims if it had known the truth. The insurer also maintained it is not the responsibility of MA plans to verify providers are providing correct information when they file claims.
A qui tam lawsuit in Wisconsin, filed last July, charges UnitedHealth with hiding hundreds of complaints of enrollment fraud and other violations as part of a scheme to collect unearned bonus payments. That case has been dismissed, according to the insurer.
In April 2017, a federal judge in Washington, D.C., determined UnitedHealth could sue CMS over the agency’s 2017 Medicare Advantage overpayment rule. The rule lets CMS treat overpayments like FCA breaches if insurers fail to return them within 60 days of identifying them. The goal was to reduce Medicare fraud and upcoding.
UnitedHealth sued CMS in January 2016, claiming the rule allowed payers to be sued for negligence under the FCA — a lower bar than the recklessness standard usually applied in such cases.
Insurers in MA plans receive an annual fee for each beneficiary plus monthly risk adjustment payments for each enrollee based partly on their health status.
The program’s design makes it any easy target for fraud. CMS estimates it overpaid MA plans by about $14.1 billion in 2013. MA insurers received about $160 billion in 2014 for roughly 16 million beneficiaries — about 9.5% of which was improper, according to a government watchdog report.