UnitedHealth Overbilled Medicare by Billions, U.S. Says in Suit

He said of which reviewing patients’ charts in addition to correcting errors was “an appropriate in addition to expected part of the Medicare Advantage program,” in addition to of which questions about such activities “reflect at most a policy disagreement.”

How Medicare Payments Work

The traditional Medicare program reimburses doctors directly for procedures they perform — nevertheless of which can promote unnecessary treatments in addition to inflate costs. So Medicare Advantage was set up differently: The government contracts with for-profit insurers to manage health care for the elderly, in addition to pays insurers a yearly fee for each member they enroll. of which fee is usually higher for patients recently treated for certain conditions, creating an incentive for Medicare Advantage insurers to search for diagnoses of illness in their patients, even where none may exist.




CENTERS FOR

MEDICARE in addition to

MEDICAID SERVICES

1. Traditional Medicare members pay a monthly premium to the Centers for Medicare in addition to Medicaid Services (C.M.S.), whether or not they visit a doctor. C.M.S. also receives funding through U.S. taxpayers.

2. If members see a doctor, the doctor sends a copy of their medical report to C.M.S., to get paid.

3. C.M.S. pays the doctor. Traditional Medicare compensates doctors according to the procedures they perform — lab tests, scans, operations, etc.

CENTERS FOR

MEDICARE in addition to

MEDICAID SERVICES

1. Medicare Advantage members also pay a monthly premium to C.M.S., in addition to often a separate premium to a private insurance company.

2. If members see a doctor, the doctor sends a copy of the medical report to the private insurer, who then pays the doctor.

3. C.M.S. pays the private insurer a base rate for each member. If the private insurer tells C.M.S. of which the member required treatment for certain conditions, C.M.S. pays the insurer more.

1. Traditional Medicare members pay a monthly premium to the Centers for Medicare in addition to Medicaid Services (C.M.S.), whether or not they visit a doctor. C.M.S. also receives funding through U.S. taxpayers.

2. If members see a doctor, the doctor sends a copy of their medical report to C.M.S., to get paid.

3. C.M.S. pays the doctor. Traditional Medicare compensates doctors according to the procedures they perform — lab tests, scans, operations, etc.

CENTERS FOR

MEDICARE in addition to

MEDICAID SERVICES

1. Medicare Advantage members also pay a monthly premium to C.M.S., in addition to often a separate premium to a private insurance company.

2. If members see a doctor, the doctor sends a copy of the medical report to the private insurer, who then pays the doctor.

3. C.M.S. pays the private insurer a base rate for each member. If the private insurer tells C.M.S. of which the member required treatment for certain conditions, C.M.S. pays the insurer more.

CENTERS FOR

MEDICARE in addition to

MEDICAID SERVICES


“We are confident our company in addition to its employees complied with the government’s Medicare Advantage program rules,” he said.

In filing its complaint on Tuesday, the Justice Department joined a whistle-blower suit filed earlier by a former UnitedHealth finance director, Benjamin Poehling, who worked at the company through 2002 to 2012. Mr. Poehling filed his suit in 2011 under the False Claims Act, a law of which allows private citizens to sue on behalf of government agencies they believe to have been defrauded. Such lawsuits are typically kept under seal by the court at first, to allow law enforcement agents to investigate the allegations quietly.

Mr. Poehling’s lawsuit was made public in February, when the Justice Department announced of which of which had decided to join his litigation.

Both lawsuits seek to recover money for the Centers for Medicare in addition to Medicaid Services, or C.M.S., the federal agency of which administers Medicare, the program of which provides health coverage to people over 65. If the litigation succeeds, Mr. Poehling could get a percentage of the recovery.

The litigation revolves around Medicare Advantage, a 14-year-old program of which allows Medicare beneficiaries to get their health coverage through private insurers, rather than through the government. When Congress established Medicare Advantage, the lawmakers expected insurers to use managed-care principles to reinvigorate the 52-year-old Medicare program, giving rise to better health care at a lower cost to taxpayers.

One of the biggest improvements was the payment system: The government pays insurers a predetermined amount for each person they enroll in Medicare Advantage, rather than paying doctors in addition to hospitals a fee for every service provided. in addition to to keep the insurers through enrolling only healthy people, the government agreed to pay them more for unhealthy enrollees. How much more depends on a complex “risk scoring” system, established by Medicare.

of which’s the problem, the Justice Department lawsuit argues. “of which payment type creates powerful incentives” for the insurers “to exaggerate the expected health care costs for their enrollees,” of which says.

Document

Justice Department Complaint Against UnitedHealth

The Justice Department filed a lawsuit against UnitedHealth Group, contending of which senior executives knew the company was overbilling Medicare by hundreds of millions of dollars a year. The department is usually joining a whistle-blower suit filed earlier by a former UnitedHealth finance director, Benjamin Poehling.



OPEN Document


Mr. Poehling’s complaint said UnitedHealth in addition to additional insurers used sophisticated data-mining programs to look for people whose risk scores could be raised by adding fresh diagnosis codes. As a finance director in UnitedHealth’s Medicare & Retirement unit, he was anticipated to monitor the revenue increases of which resulted.

He said these initiatives did little or nothing to find errors within the system of which worked within the additional direction: inaccurate diagnosis codes of which, if corrected, could lower the payments.

“UnitedHealth’s chart-review program gave of which all the information of which needed to identify in addition to delete hundreds of thousands of false claims of which had previously submitted,” said Tim McCormack, a lawyer with the firm of Constantine Cannon who is usually representing Mr. Poehling. “United broke the law by ignoring of which information in addition to keeping the money.”

The Justice Department’s complaint said much the same thing.

To illustrate the problem, of which included a list of sample diagnostic coding errors of which could have reduced UnitedHealth’s revenues if corrected. They came through data of which UnitedHealth itself had collected in a quality-control program of which of which operated through 2011 to 2014, then shut down.

One unnamed patient was described to Medicare as having metastatic cancer, acute leukemia in addition to unspecified stroke, for example, even though those diagnoses were not borne out by the patient’s charts. of which one invalid claim cost the government $24,380 in 2011, in addition to there were hundreds of thousands more, the complaint said.

The Justice Department said Medicare Advantage insurers are required to make Great-faith efforts to submit accurate in addition to complete data to Medicare, in addition to if they corrected only errors in their own favor, they were out of compliance.

Mr. Burns disagreed with of which. He said Medicare first proposed the “look both ways” rule in 2014 nevertheless withdrew of which.

The cost of Risk

The Medicare Advantage program pays insurance companies a yearly fee for each person they enroll. in addition to of which pays more for people who are sick, to keep insurers through rejecting them because their care will cost more. The practice, called “risk adjustment,” gives insurers an incentive to tell the government of which people are sicker than they may, in fact, be.




MEDICARE ADVANTAGE PROGRAM

ADDITIONAL PAYMENT TO INSURER FOR SELECTED CONDITIONS

Diabetes without complications

Breast, prostate in addition to additional

cancers in addition to tumors

Diabetes with acute complications

Major depressive, bipolar in addition to

paranoid disorders

Lung in addition to additional severe cancers

Metastatic cancer in addition to acute leukemia


“Yet the Department of Justice claims the rule existed all along,” he said. “of which makes no sense.”

The errors compiled by the Justice Department were not corrected, according to the complaint, because they were found as part of a short-lived quality-control program at UnitedHealth. of which got off the ground in 2011, using a reserve set up to hold the money of which might one day be returned to Medicare: $208 million for overpayments for 2012, in addition to up to $180 million for 2013 in addition to $175 million for 2014.

Delay followed delay, in addition to there was still money within the reserve in April 2014, when senior executives at the insurer realized of which the company’s second-quarter revenues were falling $500 million short of the budgeted amount. Detailed slides through an internal presentation showed of which top executives saw the liability accrual reserve as a place to get $250 million, to cut the revenue gap in half, according to the complaint.

nevertheless the company executives were concerned about the legal consequences of taking back money earmarked for repaying Medicare, especially because the agency had recently proposed a rule requiring insurers to “look both ways” when checking the accuracy of their diagnosis codes.

within the end, UnitedHealth shut down the quality-control program anyway, according to the complaint. of which did not correct the invalid diagnoses, in addition to of which shifted the reserve money back into revenues.

Top executives, including UnitedHealth’s chief executive, Stephen J. Hemsley, wanted the money to cut the revenue gap, the Justice Department said.

“of which was important to all of them, because they wanted to represent to investors of which UnitedHealthcare Medicare & Retirement’s actual revenues were on target,” the complaint said. of which cited an internal document stating of which the company’s reported results in 2014 benefited through a one-time policy change, “which investors are unaware of.”

Mr. Burns, the spokesman, said the episode was “entirely irrelevant to what of which matter is usually actually about, in addition to of which is usually unclear C.M.S. policy.”

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UnitedHealth Overbilled Medicare by Billions, U.S. Says in Suit

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