A whistleblower lawsuit in Wisconsin alleges that UnitedHealth Group “concealed hundreds of complaints of enrollment fraud and other misconduct from federal officials as part of a scheme to collect bonus payments it didn't deserve.” UnitedHealth rejected the allegations.
The lawsuit, which was filed in October 2016 but wasn’t unsealed until last week, said UnitedHealth knew of complaints about a sales agent who allegedly forged signatures on enrollment forms.
Another sales agent, whom UnitedHealth fired, reportedly engaged in a scheme in which the agent promised iPads for people to sign up and stay with UnitedHealth for six months.
The legal concerns for UnitedHealth are mounting.
The lawsuit is the latest whistleblower case alleging problems with UnitedHealth and Medicare Advantage (MA). United, which is the largest payer in the MA market, is also involved in whistleblower lawsuits that claim the payer received MA overpayments.
One of the cases, which was filed by the Department of Justice, alleges that the payer changed diagnosis codes to make patients seem sicker. That suit also claims UnitedHealth officials received bonuses for changing the codes.
In another overbilling case, UnitedHealth filed a motion in federal court requesting the court dismiss the suit. In that case, UnitedHealth said the suit “fails properly to plead two elemental aspects of its claims: That United knowingly submitted false attestations, and that the government would have refused to pay United’s claims if it had known the truth,” according to the suit. The payer also said that it’s not MA plans’ responsibility to check whether healthcare providers are providing correct information when they submit claims.
UnitedHealth has more than 50 MA and drug prescription plans. Out of the about 19 million MA beneficiaries, UnitedHealth covers about 3.6 million of them. UnitedHealth picked up more than 800,000 MA beneficiaries over the past year and its market share increased from 21% to 24%. The second largest MA payer, Humana, is looking to expand MA offerings after dropping out of the ACA exchanges market in 2018.
MA now accounts for one-third of Medicare beneficiaries, but UnitedHealth thinks that percentage could swell to 50%. Currently, the MA market is dominated by a handful of payers. UnitedHealth, Humana and Blue Cross Blue Shield affiliates make up 57% of MA enrollment. The top eight payers in MA comprise about three-quarters of the market, according to the Kaiser Family Foundation.
Though MA is popular with the payers involved in the program, the payment system is open to fraud. CMS estimated that it overpaid $14.1 billion in 2013 to MA organizations. Medicare Advantage payers received about $160 billion in 2014 for approximately 16 million beneficiaries. CMS estimated about 9.5% of those payments were improper.
The news about the unsealed lawsuit comes a week after UnitedHealth Group announced that its second-quarter revenues grew 8% year-over-year to $50.1 billion. Operations cash flow increased 29% year-over-year to $2.2 billion in the second quarter and net earnings of $2.32 per share grew 28%.
UnitedHealth said its Medicare revenues grew by $2.5 billion, which is 17.2% year-over-year.