A recently filed whistleblower lawsuit alleges UnitedHealth Group and other health plans that hired subsidiaries of the insurance company routinely submitted false information about the conditions of patents to boost reimbursement rates from Medicare. If the allegations turn out to be true, the fraudulent scheme could have generated hundreds of millions to billions of dollars in government overpayment.
The U.S. Department of Justice announced it would join the case, giving some indication as to how seriously it views these allegations. The case focuses on Medicare Advantage plans, which are owned by private insurance providers to help manage care for people who have coverage under Medicare.
According to the lawsuit, insurers submitted forms for diagnoses that members of the health plans did not actually have and were not treated for in that year. Insurers also allegedly claimed members were being treated for conditions that were more serious than those they actually had. The plans also allegedly refused to correct the claims that were submitted to the government.
False Claims Act cases common whistleblower suits
Upcoding cases are among the most common examples of False Claims Act (FCA) violations. Over the years, the Department of Justice has frequently joined in on whistleblower cases that targeted allegations of hospital chains upcoding patient cases to maximize their reimbursement rates. This case is particularly noteworthy as it is the first big FCA case to be tackled by the Trump Administration. It could result in more than a billion dollars of recovery.
Federal auditors have also paid attention to Medicare Advantage plans in the past. A 2014 study revealed the 2013 fiscal year saw an estimated $11.8 billion in improper payments.
If you believe you have uncovered evidence of a False Claims Act violation, contact an experienced Dallas attorney at Whistleblower Law for Managers.