Health Insurers Charged under the False Claims Act – a Serious Concern

by | Published on May 17, 2017 | Medical Record Review

Medical claims review is an important step when reimbursing for medical services to ensure that provider billings are accurate and that the appropriate services are provided to the patient. Insurers utilize this service to determine patient eligibility and other details and it is expected that these carriers will focus on providing fair reimbursement for the medical services the patient uses. It is a matter of great concern when health insurers fall under the shadow of doubt with allegations against them of extorting taxpayers’ money.

On May 16th the federal government sued UnitedHealth Group alleging that this healthcare company wrongly received at least $1 billion in “risk adjustment” payments based on inaccurate data submissions. The Feds questioned the “one-sided” chart reviews that focused on maximizing taxpayer dollars to the nation’s largest health insurer, but did not correct the errors that supposedly increased the company’s revenue. The risk adjustment payments made to private insurers that operate Medicare Advantage plans are a very popular way for beneficiaries to obtain the government health insurance due to them. UnitedHealthcare, UnitedHealth Group’s health insurance division, is the United States’ largest provider of Medicare Advantage plans.

The federal government filed this civil fraud suit against the company following a whistleblower case brought by a former UnitedHealth Group employee who worked for the company in the Twin Cities.

In Medicare Advantage plans, health insurers are paid a per-member per-month payment for enrollees. The fees can be increased when health plans submit information regarding an employee’s health that justifies a higher “risk score” for the patient. These adjustments are intended to make sure that Medicare Advantage plans are paid more for enrollees expected to incur higher healthcare costs. The information about diagnoses must be supported by the patient’s medical documentation that is subjected to a comprehensive medical records review. This is to ensure that Medicare does not make wrongful payments to health insurers.

The lawsuit filed by the government highlighted UnitedHealth’s program to review charts, referring to it as a “one-sided revenue-generating program”. The insurer employed medical chart review professionals to review millions of medical records it had collected and find diagnoses that the providers themselves had not reported to United for their patients. The results of the chart reviews were used to increase government payments while ignoring (in bad faith) other information from the very same reviews that would have helped reduce payments.

In this particular whistleblower case, the employee said that the data mining projects he had monitored could increase the federal payments to United Health by nearly $3,000 for each new diagnosis found. He said that his company did not bother to look for health conditions that do not raise risk scores. Bonuses were paid to him and his team when they hit their revenue targets. But there were no bonuses for better health outcomes or for more accurate medical charts. The entire focus was on increasing the bottom line, and not about delivering better care to members. This whistleblower started working with United Health in 2002, filed his lawsuit in 2011, and left the company by the end of 2012 when the case was still under seal.

In some states, the insurers are pulling out of the Affordable Care Act exchanges, but staying in the Medicare Advantage program. This could substantiate the UnitedHealth whistleblower’s allegation – Medicare Advantage may be offering a way for insurers to get extra money from the federal government. The Justice Department is investigating four other Medicare Advantage insurers – Humana, Aetna, Health Net and Cigna’s Bravo Health.

This should come as no surprise because analysts and auditors have been warning for at least a decade that Medicare Advantage is highly vulnerable to cheating since risk scoring was included, over the 2004 – 2008 period.

  • An audit by the inspector general of the Department of Health and Human Services had revealed overpayments of up to $650 million in 2007. It predicted even more in 2008. Unfortunately, budget cuts came and those audits stopped.
  • In 2016, the Government Accountability Office reported that the CMS had identified $14.1 billion of overpayments to insurers in 2013. They didn’t have a clear plan for recovering the money.
  • In 2014, the Center for Public Integrity, a non-profit research group analyzed the available Medicare Advantage data and found that insurers had reaped about $70 billion in overpayments during the period 2008 to 2013.

Even while mentioning in a statement that the claims asserted against UnitedHealth are allegations only, and there has been no determination of liability, the lawsuit filed against the insurer also highlights the fact that since at least 2005, United has known that a significant percentage of diagnoses reported by providers to it are invalid because the beneficiaries’ medical records do not substantiate that they have the medical conditions identified by the diagnosis codes the providers have reported.

Whistleblower cases filed under the False Claims Actare brought on behalf of the federal government and aim at recovering funds for the government. The whistleblowers themselves would receive a portion of the recoveries. The amounts in question industrywide are shocking – analysts estimate inappropriate Medicare Advantage payments at $10 billion or more each year.

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