Massachusetts Attorney General Sues UnitedHealthcare Over Fraudulent Practices
Massachusetts Attorney General Andrea Joy Campbell has initiated a lawsuit against UnitedHealthcare, a branch of UnitedHealth Group, alleging that the company improperly classified low-income seniors as sicker than they have been over the past decade to boost its profits.
According to Campbell, UnitedHealthcare may have received at least $100 million more from Massachusetts’ Medicaid program, known as MassHealth, due to inflated payments resulting from these fraudulent diagnoses.
This lawsuit marks one of the early cases to charge fraudulent documentation, or “upcoding,” involving Medicare patients who are also part of state Medicaid plans. Such claims come following a series of investigations focusing on Medicare Advantage practices. The allegations in Massachusetts suggest that not just UnitedHealth but possibly other insurance companies are employing similar upcoding methods for dual-eligible individuals—those enrolled in both Medicare and Medicaid—potentially drawing scrutiny from state regulators.
Prior reports indicated that UnitedHealth Initiatives used numerous healthcare providers who pushed for higher documentation of diagnoses, enabling claims for greater amounts from the federal government.
Massachusetts has a program for seniors known as Senior Care Options (SCO), which assists low-income residents aged 65 and above who receive Medicare and live at home or in long-term care facilities. Around 75,000 people are enrolled in this program, costing the state roughly $3 billion annually. Notably, UnitedHealthcare serves more members than any other insurance provider in this category.
Like Medicare Advantage, the SCO program pays health insurers depending on the perceived health status of enrolled individuals. Health statuses are categorized into three levels, with payments varying by the health conditions reported. An investigation revealed that from January 2015 to December 2025, UnitedHealthcare frequently categorized members into higher levels, even when these individuals were not receiving treatment for their reported conditions or did not meet criteria for such classifications.
The Massachusetts Attorney General’s investigation also uncovered that UnitedHealthcare reviewed its coding practices in 2018 and 2019, realizing it did not align with standards but nonetheless chose not to rectify the overpayments. The lawsuit has been filed in Suffolk Superior Court.
“State managed care plans are required to act with integrity on behalf of their participants and the state’s Medicaid program resources. Our investigation found that UnitedHealthcare knowingly violated these obligations by manipulating health ratings to enhance profits,” Campbell stated in a press release.
She added, “This case sends a clear message that no company is above the law. My office will ensure that companies exploiting vulnerable residents and misappropriating taxpayer dollars are held accountable.”
Campbell was unavailable for an interview, and UnitedHealth opted not to comment on the lawsuit.
Simultaneously, federal investigations are ongoing regarding Medicare Advantage Plans over allegations that companies, including UnitedHealth, have exaggerated diagnoses in older adults, with some companies having reached settlement agreements to address these concerns.
