The Justice Department’s long-running legal battle against UnitedHealth Group faced a significant setback recently. A special master ruled that the government did not provide enough evidence to support its claims of overpayments related to Medicare Advantage. This case has been ongoing for over a decade, stemming from allegations that UnitedHealth inflated patient diagnoses to receive more than $2 billion in improper payments.
Special Master Suzanne Segal stated that the Justice Department’s case relied too much on speculation. She noted that the government failed to show any solid proof that UnitedHealth had exaggerated the health conditions of its patients. In her initial ruling, Segal recommended that the court dismiss the case against the health insurer.
The lawsuit was initially filed in 2011 by whistleblower Benjamin Poehling, a former employee of UnitedHealth. The Justice Department took over the case in 2017, claiming that from 2009 to 2016, Medicare paid UnitedHealth more than $7.2 billion based on questionable billing practices. The DOJ alleged that the company conducted chart reviews to find additional diagnoses and added billing codes that were not properly supported by medical records.
Despite these claims, Segal pointed out that audits by the Centers for Medicare & Medicaid Services (CMS) found that about 89% of UnitedHealth’s billing codes were backed by patient records. This finding undermined the government’s argument that the company was engaging in widespread overbilling.
UnitedHealth welcomed the ruling, with a spokesperson stating that it confirmed the absence of evidence for the government’s claims. They emphasized that the company had been transparent about its practices with CMS officials. The Justice Department has not yet commented on the ruling but has the option to appeal within two weeks.
This decision is seen as a significant defeat for the government, according to legal experts. The outcome could influence future cases involving Medicare Advantage plans, which have been under scrutiny for their billing practices. As the Medicare Advantage sector continues to grow, with around 33 million enrollees, the implications of this ruling could be far-reaching.