UnitedHealth's headquarters in Minnetonka, Minnesota. Credit: Steve Niedorf
The state of Massachusetts on Friday filed a lawsuit alleging that UnitedHealthcare defrauded MassHealth, the state's Medicaid program, of at least $100 million. The insurer falsely manipulated the health status of MassHealth members enrolled in its Senior Care Options plan to secure higher payments from the Commonwealth, according to the complaint.
"The state's managed care plans need to act in good faith on behalf of their members and the financial resources of our state's Medicaid program," Attorney General Joy Campbell said in a news release. "Our investigation found that UnitedHealthcare knowingly violated these obligations by manipulating health assessments to increase its profits."
The Senior Care Options program serves eligible members aged 65 or older living in designated service areas across Massachusetts. Enrollees must receive a comprehensive in-home clinical assessment to determine the member's health status and assign them one of three levels of care, ranging from the least serious and lowest payment rate to the most serious and highest payment rate. UnitedHealthcare is the largest provider of these plans in the state.
The attorney general's office alleges that UnitedHealthcare manipulated the health statuses of its members to increase profits in three principal ways:
- First, it submitted assessments of members in the plan that led to their classification as level two, which is reserved for members with behavioral health or substance use disorders. It classified members by identifying in its submissions to MassHealth that members had diagnoses such as depression or anxiety, even though those members lacked any corresponding diagnosis or treatment associated with behavioral health or substantive use disorders.
- Second, the insurers improperly assessed many members in the plan with health conditions satisfying level three classifications, which is reserved for members with the most serious health conditions, even though those members did not qualify for level three services. Beginning in 2018 and continuing into 2019, UnitedHealthcare became aware through a series of internal reviews that many of its members at level three had been improperly classified. Nevertheless, it never disclosed to MassHealth that it had been improperly paid at higher rates for these members before their being downgraded, nor has it repaid MassHealth for any of the improperly inflated payments.
- Third, UnitedHealthcare submitted assessments to MassHealth for members representing that those members needed daily skilled nursing services although they didn't need or receive these services. As a result, UnitedHealthcare received higher payments from MassHealth for these members than it should have.
The attorney general's office alleges that these failures were intentional and the result of
a "growth-at-al-costs" strategy employed by UnitedHealthcare that incentivized and encouraged its field nurses to code MassHealth members as sicker or less able than they were.
"This lawsuit sends a clear message that no company is above the law," Campbell said, "and my office will hold companies accountable for exploiting vulnerable residents and misusing taxpayer dollars."
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