7 questions about UnitedHealth's false claims lawsuits, answered

This month the Justice Department intervened in two whistle-blower lawsuits filed under the False Claims Act against Minnetonka, Minn.-based UnitedHealth Group.

Here are seven questions — and answers — regarding the lawsuits.

1. When did the DOJ intervene?

In February the department first intervened in a whistle-blower lawsuit filed by former UnitedHealth executive Benjamin Poehling under the qui tam provision of the False Claims Act. The department then filed a formal complaint against the insurer May 16.

The department filed another complaint against the insurer on May 1, which involved a separate case filed under the False Claims Act by James Swoben. The lawsuits allege similar claims.

2. What is the False Claims Act?

The False Claims Act aims to fight fraud against the federal government by allowing private individuals or parties to sue for the government and receive a percentage of recovered money.

3. What is the difference between the two whistle-blower suits?

Mr. Poehling, former finance director of UnitedHealthcare Medicare and Retirement, filed his lawsuit in 2011. Mr. Poehling claimed UnitedHealth used erroneous coding to inflate Medicare Advantage risk scores to increase reimbursement. Mr. Poehling alleges he and other employees' performance was evaluated based on how well they achieved risk adjustment targets they were given. Mr. Poehling filed his suit against 15 companies, but the DOJ has only intervened in the cases involving UnitedHealth and its subsidiary WellMed Medical Management, according to The New York Times. The case is United States of America ex rel. Benjamin Poehling v. UnitedHealth Group, Inc., No. 16-08697.

Mr. Swoben, a medical data consultant, filed his lawsuit in 2009. He claimed UnitedHealth billed Medicare higher payments for patients by "systematically ignoring information that would have led to decreased payments," such as unsupported diagnosis codes not validated by medical records. The Swoben complaint is United States ex rel. Swoben v. Secure Horizons, et al., 09-5013. 

4. How much money in on the table?

The DOJ claimed the payer defrauded the government more than $1 billion in false claims.

5. How long has the alleged abuse been going on?

The DOJ argues the scheme occurred throughout the past decade.

6. How has UnitedHealth responded?

The payer denied the allegations and said it would contest the lawsuit. 

7. What's next?  

Both lawsuits are pending in the United States District Court for the Central District of California.   

More articles on payer issues:
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UnitedHealth to close insurance-primary care subsidiary Harken Health: 5 things to know
NY Assembly passes single-payer healthcare plan

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