Star
Tribune (Minneapolis, MN)
February 13, 2018
Feb. 13--A whistleblower case
alleging that Minnetonka-based UnitedHealth Group defrauded the federal
Medicare program can move forward, a federal judge ruled Monday, although the
decision narrowed the set of claims that the government might pursue.
The ruling came in a case brought by a former UnitedHealth Group
employee in Minnesota alleging the company submitted false information about
patient conditions to collect higher payments.
It was unsealed a year ago after the federal government joined
the case. They alleged that UnitedHealth Group engaged in "one-sided"
reviews of patient charts, looking for ways to boost payments without
correcting erroneous data that would lower reimbursement.
In an order Monday, U.S. District Judge Michael Fitzgerald
dismissed claims related to Medicare payments before 2009, and he said three of
six claims would be dismissed unless the government amended its filing. But
Fitzgerald denied UnitedHealth Group's motion to dismiss an allegation that the
company avoided an obligation to refund money to the government, as well as
related claims for unjust enrichment and payment by mistake. In the order, he
gave the government until Feb. 26 to amend its complaint.
"We reject the government's remaining claims and will
continue to aggressively contest them," a UnitedHealth Group spokesperson
said in a statement.
UnitedHealth Group is the largest publicly traded company in
Minnesota. It operates UnitedHealthcare, which is the nation's largest insurer,
and a health services division called Optum. UnitedHealthcare receives payments
from Medicare, the federal health insurance program that primarily serves
Americans 65 and older, because a growing share of Medicare beneficiaries opt
to receive their benefits through Medicare Advantage plans sold by private
insurers.
At issue is data Medicare uses to make "risk
adjustment" payments that are intended to compensate Medicare Advantage
plans for providing coverage to beneficiaries with more complicated health
problems.
Former UnitedHealth Group finance director Benjamin Poehling of
Minnesota first filed his lawsuit under seal in 2011; it became public in
February 2017 after the Justice Department joined the case. Subsequently, the
federal government joined a separate lawsuit from whistleblower James Swoben, a
California resident, that raised similar allegations against UnitedHealth
Group. That suit was dismissed.
Monday's ruling suggested the Poehling case and the Swoben case
have a similar problem by failing to allege the government would not have made
the risk adjustment payments had it known of alleged problems with the
underlying data.
Fitzgerald dismissed the government's claims related to risk
adjustment payments before 2009, saying the government and UnitedHealth Group
appeared to be in agreement about whether congressional revisions to a statute
in 2009 were intended to apply retroactively.
But the judge agreed to let move forward an allegation that the
company failed to delete invalid diagnoses in submissions to the government and
failed to return Medicare overpayments.
Under traditional Medicare, the federal program reimburses
doctors for procedures performed. Under Medicare Advantage health plans,
insurers pay doctors and hospitals when enrollees use services. The government,
in turn, pays the health plans a set per-member, per-month rate that's meant to
cover health care costs and the insurance company's overhead.
These set rates are modified with risk adjustment payments,
which take into account an individual patient's illness or underlying
condition. The rules for those risk scores have been controversial in the past.
UnitedHealth Group sued the federal government in January 2016 over a change in
guidance on how to assess the health status of enrollees. That case has not yet
concluded.
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