The lawsuit cites an instance in which UnitedHealthcare allegedly overcharged MassHealth by $133,000 over the span of five years for a patient who allegedly needed assistance with tasks like bathing, grooming, and dressing. The patient was diagnosed with Type 2 diabetes, hypertension, and arthritis, but, upon investigation, “demonstrated complete independence” with the assistance of over-the-counter painkillers.
Massachusetts Attorney General Andrea Joy Campbell has filed a lawsuit against UnitedHealthcare Insurance Company, claiming that it falsely manipulated the health status of MassHealth members enrolled in certain senior plans to secure higher payments from the state.
In a statement announcing the lawsuit, Campbell’s office said it believes that UnitedHealthcare’s alleged fraud has cost the state’s Medicaid program at least $100 million.
“The state’s managed care plans need to act in good faith on behalf of their members and the financial resources of our state’s Medicaid program. Our investigation found that United Healthcare knowingly violated these obligations by manipulating health assessments to increase its profits,” Campbell said in a press release. “This lawsuit sends a clear message that no company is above the law, and my office will hold companies accountable for exploiting vulnerable residents and misusing taxpayer dollars.”
MassHealth’s Senior Care Options, or SCO, serves eligible members ages 65 and over who live in designated service areas across the state. In order to qualify for benefits, customers must typically receive an in-home clinical assessment, with the results determining their payment rate.
The lawsuit accuses UnitedHealthcare of manipulating members’ health statuses to obtain higher rates of pay and thereby increase its profits. Campbell’s office provides several examples of the strategies that United allegedly used to defraud the state. In some instances, the company elevated customers with conditions like depression and anxiety to Level 2 pay rates, despite that level being reserved for members with “behavioral health or substance abuse disorders.” United also purportedly knew that some of its Level 3 members had been improperly classified but failed to notify MassHealth or make any attempt at repayment.
Reuters notes that, according to Campbell’s office, several former nurses reported that UnitedHealthcare generally encouraged “upcoding” by entering misleading diagnoses. Patients who complained of recurring headaches, for instance, might be diagnosed with migraines despite not meeting all the appropriate diagnostic criteria.
The lawsuit cites an instance in which UnitedHealthcare allegedly overcharged MassHealth by $133,000 over the span of five years for a patient who allegedly needed assistance with tasks like bathing, grooming, and dressing. The patient was diagnosed with Type 2 diabetes, hypertension, and arthritis, but, upon investigation, “demonstrated complete independence” with the assistance of over-the-counter painkillers.
The lawsuit was filed Friday in Suffolk County Superior Court in Boston. It accuses UnitedHealthcare of charges including the submission of false claims, breach of contract, and unjust enrichment.
Sources
Massachusetts sues UnitedHealth insurance unit for alleged Medicaid fraud
Press Release AG Campbell Sues United Healthcare for Defrauding MassHealth Out of $100 Million
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