UnitedHealth wins ruling over $2B in alleged Medicare Advantage overpayments – Minnesota Reformer

The Department of Justice's longtime court battle forced United Health Group to repay billions of dollars with overpayments of Medicare Advantage, and hit a big set-off Monday when Special Masters determined the government could not prove the case.

In the United Health discovery, Special Master Suzanne Segal found that DOJ had not presented any evidence to support the allegations that the giant health insurance company exaggerated the illegal pocketing of over $2 billion in sick patients.

“The mere possibility of overpayment is not enough for the government to carry that burden,” Segal wrote in his first ruling. She recommended that UnitedHealth be allowed to file a claim to dismiss the case. Recommendations presented to federal judges processing the case can be appealed within two weeks.

The civil fraud case against UnitedHealth Group, the country's largest Medicare advantage insurance company, was filed in 2011 by former company employee Whistlebower Benjamin Poehling. DOJ I've taken over Case from 2017. Medicare's advantage is a personalized alternative to traditional Medicare programs for seniors.

“After more than a decade of DOJ's wasteful and expensive challenges to the Medicare Advantage business, the Special Master concluded that there was no evidence to support DOJ's claim that we were overpaying or that we did something wrong.”

Justice Department spokesman Wyn Hornbuckle said the agency would not comment on the ruling filed in federal court in Los Angeles. The attorney for whistleblower Pauling did not have any comment.

Medicare benefits from a higher-cost health plan to cover sick patients, but it requires that their condition be properly documented in their medical records.

DOJ claims it paid more than $7.2 billion to UnitedHealth Group from 2009 to 2016 based on the company's efforts to raise revenue by checking patient records, finding additional diagnoses and adding medical billing codes to the files. According to the DOJ, Medicare would have paid the company $2.1 billion less if it removed the unsupported billing code.

The Justice Department also claimed in reviews of these charts that the health insurance giant ignored overcharges that could have reduced bills.

However, the special master appointed by US District Judge Fernando Holguin concluded that government cases “relied entirely on speculation and assumptions about what the codes found by United Coders actually mean.”

“If this is standing there, I think it's a big defeat for the government,” said William Hanagami, the lawyer who represented another whistleblower in one of the earliest cases that claim claim fraud by Medicare Advantage insurance companies. Hanagami said he hopes the government will appeal the decision.

Segal said an executive at UnitedHealth told the Center about the chart review policy to Medicare and Medicaid Services officers at an April 2014 meeting. At the time, CMS was considering regulations restricting the use of chart reviews, but the agency Restrictions have been retarded We are under pressure from the insurance industry. At the time, CMS officials described the industry's response as “a fuss.”

The special master noted that United requested a meeting with CMS officials, and she called it “opposition to concealment.”

“The problem with the government's allegations is that because the government knew the very chart review practices that it now claims to prevent United from learning it, the government could not rely on unified actions or omissions in determining whether they were victims of overdose,” Segal wrote.

Segal said a CMS audit of UnitedHealth's Medicare Advantage Plan found that approximately 89% of the billing codes are supported by the patient's medical records. The audit results “undercut” the government's claim that the company is engaged in a widespread overbuilding.

“The lawsuit has been on hold for over a decade,” she writes. it's not. ”

This decision will be made when UnitedHealth is facing New research Handling Medicare Advantage Coding, including a new Department of Justice review.

Medicare Advantage Insurance Plans have grown explosively in recent years Approximately 33 million members will be registeredmore than half of those eligible for Medicare.

The industry has become the target of dozens of whistleblowers litigation. Government Audit Taxpayers claim the plan is too expensive Last month's demand Chuck Grassley (R-Iowa), chairman of the Senate Judiciary Committee, where UnitedHealth explains its claims practices;

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