UnitedHealth Wins Ruling Over $2B in Alleged Medicare Advantage Overpayments

The Justice Division’s years-long courtroom battle to drive UnitedHealth Group to return billions of {dollars} in alleged Medicare Benefit overpayments hit a significant setback Monday when a particular grasp dominated the federal government had didn’t show its case.

Find for UnitedHealth, Particular Grasp Suzanne Segal discovered that the DOJ had not offered proof to assist its declare that the large well being insurer exaggerated how sick sufferers have been to illegally pocket greater than $2 billion in overpayments.

“A mere chance of an overpayment shouldn’t be sufficient for the federal government to hold its burden,” Segal wrote in an preliminary ruling. She advisable that UnitedHealth’s movement to dismiss the case be granted. The advice, which is to be offered to the federal decide dealing with the case, could be appealed inside two weeks.

The civil fraud case in opposition to UnitedHealth Group, the nation’s largest Medicare Benefit insurer, was filed in 2011 by whistleblower Benjamin Poehling, a former firm worker. The DOJ took over the case in 2017. Medicare Benefit is the privately run various to the normal Medicare program for seniors.

“After greater than a decade of DOJ’s wasteful and costly problem to our Medicare Benefit enterprise, the Particular Grasp concluded there was no proof to assist the DOJ’s claims we have been overpaid or that we did something incorrect,” UnitedHealth spokesperson Heather Soule mentioned in an announcement.

Wyn Hornbuckle, a spokesperson for the Justice Division, mentioned the company wouldn’t touch upon the ruling, which was filed in federal courtroom in Los Angeles. Attorneys for whistleblower Poehling had no remark.

Medicare pays Benefit well being plans greater charges to cowl sicker sufferers however requires that their situations be correctly documented in medical information.

The DOJ alleges Medicare paid UnitedHealth Group greater than $7.2 billion from 2009 by means of 2016 based mostly on the corporate’s efforts to spice up income by reviewing affected person information to seek out extra diagnoses and including medical billing codes to their information. In response to the DOJ, Medicare would have paid the corporate $2.1 billion much less if it had deleted unsupported billing codes.

The Justice Division additionally alleged that in these chart evaluations, the medical insurance large ignored overcharges that may have lowered payments.

However the particular grasp, who was appointed by U.S. District Decide Fernando Olguin, concluded the federal government’s case “relies upon solely on hypothesis and assumptions about what the codes discovered by the United coders really imply.”

“If this stands, I believe it’s a main defeat for the federal government,” mentioned William Hanagami, an legal professional who represented a distinct whistleblower in one of many earliest circumstances alleging billing fraud by a Medicare Benefit insurance coverage firm. Hanagami mentioned he expects the federal government to attraction the choice.

Segal famous that UnitedHealth executives informed Facilities for Medicare & Medicaid Providers officers about its chart overview insurance policies at an April 2014 assembly. On the time, CMS was contemplating a regulation to limit use of chart evaluations, however the company backed off the regulation below stress from the insurance coverage business. On the time, a CMS official described the business’s response as an “uproar.”

The particular grasp famous that United had requested the assembly with CMS officers, which she referred to as “the alternative of concealment.”

“The issue with the federal government’s allegations is that the federal government knew of the very chart overview practices which it now claims United prevented it from studying, and thus the federal government can not have been duped into counting on any motion or inaction by United in figuring out whether or not it had been the sufferer of overpayments,” Segal wrote.

Segal famous CMS audits of UnitedHealth’s Medicare Benefit plans had discovered that about 89% of billing codes have been supported by affected person medical information. The audit findings “undercut” the federal government’s declare that the corporate engaged in widespread overbilling.

“This litigation has been pending for greater than a decade,” she wrote, “and the federal government has had ample alternative to develop proof in assist of its theories. It has not.”

The choice comes as UnitedHealth faces renewed investigations into its dealing with of Medicare Benefit coding, together with a brand new Justice Division overview.

Medicare Benefit insurance policy have grown explosively lately and now enroll about 33 million members, greater than half of individuals eligible for Medicare.

The business has been the goal of dozens of whistleblower lawsuits and authorities audits alleging that the plans value taxpayers an excessive amount of cash, together with a requirement final month by Senate Judiciary Committee chair Chuck Grassley (R-Iowa) that UnitedHealth clarify its billing practices.

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