Campbell is taking legal action against UnitedHealthcare, claiming it deceived MassHealth out of $100 million.

Campbell Accuses UnitedHealthcare of Improper Practices

Massachusetts Attorney General Andrea Campbell recently accused UnitedHealthcare of “systematically defrauding” the state’s Medicaid program, claiming the company wrongfully obtained at least $100 million. The lawsuit suggests that UnitedHealthcare manipulated health assessments for elderly residents to increase reimbursements from the state. This, Campbell states, was part of a broader strategy that prioritized growth over quality, leading to issues like understaffing among nurses.

“State managed care plans must operate in good faith on behalf of their enrollees and the state’s Medicaid resources,” Campbell remarked. She emphasized that this case serves as a reminder that no company is above the law, vowing to hold accountable those that exploit vulnerable residents and misappropriate taxpayer money.

UnitedHealthcare has denied these accusations, asserting that the Attorney General’s claims are baseless and mischaracterize its Senior Care Options program, which aims to address the complex health needs of seniors. The company stated that it remains committed to supporting its members and collaborating with state partners.

The alleged fraudulent activities purportedly took place from 2015 to 2025, during which UnitedHealthcare was contracted to provide senior care through the state’s Medicaid program, known as MassHealth. United receives a fixed monthly payment for each enrolled member, based on assessments of health statuses that determine reimbursement rates.

Members with more severe health conditions receive higher payments, classified into one of three care levels, with Level 3 receiving the maximum. However, the lawsuit contends that many members were misclassified. For instance, some were identified as having behavioral health issues when, in fact, they hadn’t received any related diagnoses or treatments.

Furthermore, United was reportedly found to have incorrectly categorized numerous members as Level 3—those with the most severe conditions. Investigations in 2018 and 2019 revealed that many of these classifications were, in fact, inaccurate. While some members were downgraded to lower levels, the company did not disclose these adjustments to MassHealth, potentially contributing to inflated reimbursements.

Some members classified as Level 3 needed daily skilled nursing, but the complaint alleges that many didn’t receive these services prior to being assessed by United. The evaluations conducted by United’s nurses often included duplicate assessments from previous patients, leading to inaccuracies in diagnoses.

Campbell asserted that United has created a system driven by inadequate staffing and improper incentives, where declaring a more serious condition could reduce the number of assessments required. Additionally, while United Healthcare established a quality control team for evaluations, Campbell claimed they abandoned a significant portion of this process due to backlog concerns affecting the company’s profits.

In the fiscal year 2027, Governor Maura Healey proposed a $22.7 billion budget for MassHealth programs, marking a 7% increase from the current fiscal year. Overall spending for MassHealth is anticipated to rise by $2.3 billion over the next few years, largely due to increasing individual member costs. Notably, there has been a 13% rise in spending for long-term services and supports for elderly adults from 2024 to 2025.