UnitedHealth Group, the nation’s largest health insurer, is reportedly facing a criminal investigation by the Justice Department regarding its Medicare Advantage payments. The probe, first reported by the Wall Street Journal, centers on potential fraud related to how UnitedHealth claims payments for its Medicare Advantage plans. Medicare Advantage plans are private health insurance options that contract with the federal government to provide benefits to Medicare recipients.
The investigation reportedly focuses on whether UnitedHealth improperly inflated risk scores for its patients, leading to higher payments from the government. Risk scores are used by Medicare to adjust payments to insurers based on the health status of their enrollees; sicker patients generate higher risk scores, and thus higher payments. Federal authorities are scrutinizing whether UnitedHealth systematically exaggerated the severity of patient illnesses to boost these risk scores and, consequently, its revenue.
This investigation adds to the existing scrutiny UnitedHealth faces regarding its Medicare Advantage practices. The company has previously been subject to civil lawsuits and audits raising similar concerns about inflated risk scores. This criminal probe elevates the stakes considerably, potentially exposing the company to significant financial penalties and reputational damage. The probe is ongoing, and the outcome remains uncertain. The implications could be far-reaching, potentially reshaping how Medicare Advantage plans are reimbursed and regulated, and affecting the broader healthcare landscape. UnitedHealth has stated it is cooperating with the investigation.
