Star Tribune
(Minneapolis, MN)
Oct. 10--A federal judge has
dismissed a whistleblower lawsuit against Minnetonka-based UnitedHealth Group
that alleged the nation's largest health insurer wrongly received higher
payments from Medicare.
The payments, the suit alleged, were
based on false information about enrollee health problems that could have been
corrected.
The ruling, handed down late last
week in the U.S. District Court for Central California, does not halt a
parallel lawsuit from a whistleblower in the Twin Cities who raises similar
allegations. In that case, UnitedHealth Group recently lost its motion for a
change of venue.
Federal prosecutors opted to join
both whistleblower cases against UnitedHealth Group earlier this year. In dismissing
one of the cases last week, U.S. District Court Judge John Walter wrote that
the government could still amend portions of the lawsuit, but said prosecutors
failed to show that UnitedHealth executives knowingly submitted false
attestations about the "risk adjustment" data.
Walter called the government's
complaint "a classic 'shotgun pleading' " that failed to clearly
identify the role of each named defendant.
"The complaint ... fails to
identify the corporate officers who signed the attestations or allege that
those individuals knew or should have known that the attestations were
false," the judge wrote.
"The government has not alleged
that anyone at [UnitedHealth] undertook any action to shield the signatories of
the attestations from gaining the necessary knowledge that would have
demonstrated that they were false," Walter wrote. "Moreover, even
though the government argues that it is sufficient for someone other than the
signatories to have known the attestations were false, the government has failed
to identify anyone at [UnitedHealth] who possessed the requisite
knowledge."
A spokesman for the U.S. attorney
prosecuting the case did not comment, nor did a spokesman for UnitedHealth
Group.
The federal government filed its
complaint in May. The government alleged that UnitedHealth and its subsidiaries
combed through medical records to find data that might boost payments from
Medicare, but did not "look both ways" to correct earlier data
submissions that also generated payments.
Medicare is the federal health
insurance program that primarily serves Americans 65 and older. A growing share
of Medicare beneficiaries opt to receive their benefits through Medicare
Advantage plans sold by private insurers.
UnitedHealth's health insurance
division, UnitedHealthcare, is the nation's largest operator of Medicare
Advantage plans. The complaint focuses on UnitedHealthcare's Medicare plan in
California starting in 2005, as well as the plan's interaction with a large
group of health care providers in that state.
In Medicare Advantage, the government
pays health plans on a set per-member, per-month basis, and adjusts payments
according to an individual's health risk. To obtain these risk adjustments for
health status, Medicare Advantage plans submit diagnosis codes that the
government uses to calculate a risk score for each beneficiary.
In general, risk scores are higher --
and, therefore, generate higher payments to the insurer -- when more codes are
submitted, particularly for more serious conditions.
The complaint involves UnitedHealth
Group's funding of the cost of medical record reviews for patients treated by
the large health care provider in California, the lawsuit says, as well as the
conception and direction of those chart reviews.
In his ruling, Walter wrote that a
statute of limitations prevents the federal government from bringing claims
based on violations that were committed before May 1, 2017, when prosecutors
filed their complaint. The judge also wrote the complaint failed to allege the
agency that runs Medicare would have refused to make risk adjustment payments
had it known the facts about UnitedHealth's alleged involvement with the chart
review process.
A whistleblower lawsuit from former
UnitedHealth Group executive Benjamin Poehling, who worked for the company in
the Twin Cities, is being heard by a different judge in California's central
district. Last month, the judge denied a UnitedHealth Group motion to move the
case to Washington, D.C., where the insurer has brought a lawsuit against the
federal government over related Medicare risk adjustment rules.
In a statement last week,
UnitedHealth Group said the date of its next filing in the Poehling case hasn't
yet been determined. In the lawsuit against the federal government, the insurer
this month expects to file its opening brief on the merits.
Twitter: @chrissnowbeck
___
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(Minneapolis)
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