Dive Brief:
- UnitedHealth Group on Friday filed a counterclaim seeking damages from the federal government following a decision by the Department of Justice to abandon part of its original $1 billion lawsuit, which alleged the insurer used inaccurate risk scores to boost Medicare Advantage payments.
- The decision by DOJ in February to drop part of its lawsuit came shortly after a ruling by a federal judge that dismissed allegations the insurer infringed upon the False Claims Act by knowingly attesting data were inaccurate.
- UnitedHealth asks for the government's amended complaint be dismissed with prejudice and seeks relief "in an amount to be determined at trial."
Dive Insight:
UnitedHealth argues that DOJ's suit against its MA plans "for not performing two-way looks and other measures to review and delete codes" demanded the insurer "perform functions not required by the contracts or else face significant liability."
"As a result of any such breach of the covenant of good faith and fair dealing, the UnitedHealth MA Plans have suffered damages and are entitled to recover for these damages in an amount to be determined at trial," UnitedHealth wrote in the filing.
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.