DOJ joins whistle-blower suit accusing UnitedHealth of overbilling Medicare

The Department of Justice has intervened in a whistle-blower lawsuit alleging Minnetonka, Minn.-based UnitedHealth Group and one of its subsidiaries used erroneous coding to inflate Medicare Advantage risk scores, according to The New York Times.

According to The New York Times, the lawsuit, which was filed in 2011 and made public Thursday, alleges UnitedHealth engaged in a scheme that involved improperly overcharging Medicare by "hundreds of millions — and likely billions — of dollars."

The allegations were originally brought by Benjamin Poehling, former finance director of UnitedHealthcare Medicare and Retirement. Mr. Poehling filed his suit against 15 companies, but the DOJ is only intervening in the cases involving UnitedHealth and its subsidiary WellMed Medical Management, according to the report.

Mr. Poehling claims UnitedHealth had initiatives in place to increase Medicare reimbursement by inflating risk adjustment. Mr. Poehling alleges he and other employees' performance was evaluated based on how well they achieved risk adjustment targets they were given.

For patient care to qualify for risk adjustment factors under CMS' managed reimbursement schedules, a qualified professional must verify a patient's condition in person on a regular basis. Mr. Poehling claims UnitedHealth coding specialists would sidestep this requirement by mining patient records for evidence of a possible long-term medical condition. If they found this evidence, they would skip the in-person evaluation requirement and automatically request the higher payment.

A UnitedHealth spokesman told The New York Times the company will contest the lawsuit's allegations.

Mr. Poehling filed the suit under the qui tam provision of the False Claims Act. These cases are kept under seal while the federal government investigates the claims and decides whether to intervene.

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