The Department of Justice (DOJ) has reportedly initiated a civil fraud investigation involving UnitedHealth Group’s Medicare billing practices, amid increasing scrutiny of this company and the broader insurance industry. Sources familiar with the situation informed the Wall Street Journal that the DOJ is examining the manner in which UnitedHealth Group documents diagnoses that lead to additional payments for its Medicare Advantage plans.
According to a Wall Street Journal analysis conducted late last year, an examination of millions of Medicare records indicated a substantial rise in the number of lucrative diagnoses for patients treated by UnitedHealth-employed doctors after enrolling in the company’s Medicare Advantage plans.
UnitedHealth Group has stated that government agencies routinely review all Medicare Advantage plans to ensure compliance. The company asserted that it consistently performs at the industry’s highest standards during these reviews. They remarked that any allegation of fraudulent practices is “outrageous and false.”
Through Medicare, the federal government’s insurance program, individuals aged 65 and older can enroll in Medicare Part A and Part B, providing hospital and medical insurance. Alternatively, they have the option to select Medicare Part C, commonly known as a Medicare Advantage plan. This plan, approved by Medicare, is offered by a private company and serves as an alternative to Original Medicare, typically including Part A, Part B, and often Part D for prescription drug coverage.
Attorneys from the DOJ have been conducting interviews with medical providers mentioned in the Journal’s previous reports, which detailed how Medicare purportedly paid billions to UnitedHealth based on questionable diagnoses. These interviews reportedly occurred as recently as January 31.
In addition to the fraud investigation, UnitedHealth Group has also been facing public scrutiny regarding its denial of care, predating the untimely death of UnitedHealth CEO Brian Thompson, who was fatally shot outside a New York City hotel in December in what authorities have described as a “pre-meditated, targeted attack.”
Last year, a Senate subcommittee accused UnitedHealth Group of increasing claim denials to many patients as it implemented artificial intelligence to automate the process. The subcommittee’s report highlighted that UnitedHealth’s prior authorization denial rate for post-acute care increased from 10.9% in 2020 to 22.7% in 2022. UnitedHealth contested these claims, asserting that the report mischaracterized the Medicare Advantage program and its clinical practices.
Simultaneously, the DOJ and several state attorneys general filed a civil antitrust lawsuit to prevent UnitedHealth Group’s proposed $3.3 billion acquisition of Amedisys Inc., a rival home health and hospice services provider. The lawsuit expressed concern that the merger could jeopardize care for vulnerable patients and negatively impact home health and hospice nurses.
The Department of Justice has chosen not to comment on these developments. FOX Business also reached out to the Department of Health and Human Services’ Office of Inspector General, which is also participating in the investigation, for further comment.