The federal government’s False Claims Act (FCA) case against United Health Group (UHG) continues after major developments. In the case of U.S. ex rel. Benjamin Poehling v. UnitedHealth Group, Inc., The U.S. District Court in the Central District of California dismissed half of the claims brought through the initial qui tam suit and the government’s revised complaint. A short time later, the Department of Justice (DOJ) decided to not continue with a part of the suit and to focus on the remaining claims.
The District Court’s Decision
In February 2018, the district court analyzed the government’s amended complaint based on the FCA’s materiality requirement. Based on the Supreme Court’s decision in Universal Health Servs. Inc. v. United States ex rel. Escobar, the government must plead that their allegations are material to the government’s payment decision. They must demonstrate that, if the facts are true, the unlawful conduct influenced how much the government paid the other party.
It ultimately dismisses three of the six claims. The judge allowed one FCA claim and two common law claims to proceed. This is because the court found that the DOJ pleaded sufficient facts to demonstrate that UHG knowingly avoided repaying the Centers for Medicare and Medicaid Services (CMS) by failing to delete invalid diagnosis codes. The DOJ also sufficiently showed that such failure was material.
Government Will Not Revise Complaint
The circuit court gave the government the ability to amend their complaint and more sufficiently plead their other allegations. The DOJ announced that it would not revise the complaint to revive their claims regarding UHG’s inaccurate Medicare Advantage billing. Instead the DOJ will focus on litigating the remaining FCA and common law claims.
The DOJ’s Other Case Against UHG Dismissed
In October 2017, a federal judge in California struck down the DOJ’s other suit against UHG. U.S. District Judge John Walter ruled the DOJ’s claims were too vague to move forward. U.S. ex rel. Swoben v. Secure Horizons, et al. was based on allegations that UHG made patients appear sicker than they actually were to increase Medicare Advantage payments.
The DOJ Will Continue to Pursue Medicare Fraud
While UHG defeated this lawsuit and has had initial success with the Poehling case, these suits are not deterrents to the government. The DOJ is expected to continue to investigate FCA claims within the health care industry as well as join qui tam suits regarding Medicare fraud.
Do You Have Information About Medicare Fraud?
If you have any information regarding false claims against Medicare, a state Medicaid program, or TRICARE, then you next best step is to contact a California qui tam lawyer. At Brod Law Firm, we are here to review your situation and advise you on your legal rights and options. If the information and documentation you have demonstrates fraudulent conduct, you may have the right to pursue a qui tam case on behalf of the government.
For more information on becoming a whistleblower, call (800) 427-7020 to schedule a free consultation.
(image courtesy of Hush Naidoo)