Federal probe into UnitedHealth over alleged civil fraud claims
In a recent development, the U.S. Department of Justice (DOJ) has launched an investigation into UnitedHealth Group's Medicare Advantage (MA) billing practices, focusing on diagnosis coding that affects federal payments under the program[1][2][3]. The probe involves allegations of potential Medicare fraud tied to how the company records diagnoses to increase Medicare Advantage payments, potentially leading to higher reimbursements from the federal government[2][3].
UnitedHealth Group, which operates one of the nation's largest health insurance and pharmacy benefits management businesses[4], disclosed the investigation in a recent SEC filing, stating it proactively contacted the DOJ following media reports about the probe and has begun cooperating fully with formal DOJ requests[1][2][4]. The company maintains it has "full confidence" in its business practices and emphasized a long-standing record of compliance and responsible conduct[2][4].
The Medicare Advantage program is a government-subsidized private insurance plan primarily for individuals aged 65 and older. Diagnosis codes impact risk adjustment, influencing federal payments to insurers[5]. UnitedHealth Group has a large presence in the Medicare Advantage market, covering over 8 million people[3].
The DOJ investigation compounds a difficult period for UnitedHealth, which has also faced DOJ antitrust scrutiny over acquisitions and operational challenges reflected in recent stock declines[1][2][3]. To increase transparency and confidence, UnitedHealth has launched its own internal third-party review initiative examining policies, practices, and performance metrics related to risk adjustment coding, managed care, and pharmacy services[4].
The investigation was previously reported by The Wall Street Journal[6]. UnitedHealth Group shares slipped on Thursday, with the stock price down 1.7%, or $4.97, to $287.54[7]. The company has not mentioned any new compliance efforts or provided new information about the ongoing investigation's specific aspects or potential impact on its financial performance[1][2][3][4].
UnitedHealth Group's history includes a decade-long civil challenge involving their Medicare Advantage business, which ended with a court-appointed Special Master finding no evidence supporting wrongdoing claims[1][4]. Despite this, the company remains subject to ongoing federal scrutiny for possible fraud related to its billing practices in Medicare Advantage[1][2][3][4].
[1] - Reuters, "Exclusive: U.S. Justice Department investigating UnitedHealth Group's Medicare Advantage billing practices - sources" [2] - CNBC, "UnitedHealth Group discloses DOJ investigation into its Medicare Advantage billing practices" [3] - The Wall Street Journal, "U.S. Justice Department Investigating UnitedHealth Group Over Medicare Advantage Billing" [4] - UnitedHealth Group Inc., "SEC Filing 8-K" [5] - Centers for Medicare & Medicaid Services, "Medicare Advantage Risk Adjustment Data Validation" [6] - The Wall Street Journal, "U.S. Justice Department Investigating UnitedHealth Group Over Medicare Advantage Billing" [7] - MarketWatch, "Stock market today: Dow falls 100 points as UnitedHealth Group slides; Tesla surges after earnings beat"
- The recent investigation by the U.S. Department of Justice (DOJ) into UnitedHealth Group's Medicare Advantage billing practices is centered on potential diagnosis coding that affects federal payments.
- UnitedHealth Group, a key player in the business realm, operates a large health insurance and pharmacy benefits management business, and has a significant presence in the Medicare Advantage market, covering over 8 million people.
- The DOJ investigation, combined with previous DOJ antitrust scrutiny and operational challenges, presents a challenging period for UnitedHealth Group, as evidenced by recent stock declines.
- In response to the investigation, UnitedHealth Group has initiated its own internal third-party review to examine policies, practices, and performance metrics related to risk adjustment coding, managed care, and pharmacy services.
- Despite UnitedHealth Group's history of a decade-long civil challenge and a court-appointed Special Master finding no evidence of wrongdoing, the company continues to face federal scrutiny for possible fraud related to its Medicare Advantage billing practices.
