Justice Department joins Medicare Advantage suit against UnitedHealth

The U.S. Justice Department has joined a whistle-blower lawsuit claiming that UnitedHealth Group and affiliated health plans defrauded the Medicare program, collecting millions of dollars by claiming patients were sicker than they really were.

The lawsuit, initially brought in 2011 and unsealed Thursday after a five-year investigation by the Justice Department, alleges that Minnetonka, Minn.-based UnitedHealth has inflated its plan members’ risk scores since at least 2006 to boost payments under Medicare Advantage’s risk-adjustment program.

UnitedHealth, the nation’s largest Medicare Advantage insurer, allegedly collected payments from false claims that it treated patients for conditions they didn’t have, for more severe conditions than they had, conditions that had already been treated, or diagnoses that didn’t meet the requirements for risk adjustment, according to the suit.

A UnitedHealth spokesman denied the accusations.

Medicare Advantage payment rates are based on regional trends and utilization in traditional fee-for-service Medicare as well as adjustments to plan members’ risk scores, among other variables. Under the Medicare Advantage program, the government pays private health plans monthly amounts for every member they cover, and those taxpayer-funded payments are adjusted based on how sick someone is.

Plans that cover more members with more chronic conditions receive higher payments.