DOJ Cases Against Major Insurer United Health Group Continue

jimi-filipovski-189724-copy-300x176There are currently two False Claims Act (FCA) qui tam cases against United Health Group (UHG) pending in the Central District of California. The cases are: U.S. ex rel. Benjamin Poehling v. UnitedHealth Group, Inc. and U.S. ex rel. Swoben v. Secure Horizons, et al. The cases were brought by James Swoben, who was previously an employee of Senior Care Action Network Health Plan and a consultant within the risk adjustment industry, and Benjamin Poehling, who was the former finance director of a UHG group that managed the insurer’s Medicare Advantage Plans.

The Qui Tam Cases Against UHG


On May 2, the U.S. intervened in the Swoben False Claims Act suit against UHG based on the allegations the insurer overcharged Medicare Advantage and prescription drug programs. In the DOJ’s complaint, it alleges the insurer knowingly ignored patients’ medical conditions to increase payments it received from Medicare and funded chart reviews to increase the risk adjustment payments it reviewed. However, any information the reviews uncovered regarding misdiagnoses were disregarded to avoid repaying Medicare.

On May 16, the U.S. intervened in the Poehling case. In the DOJ’s complaint, the U.S. alleges similar unlawful actions by UHG, including ignoring information to pursue higher risk adjustment payments from Medicare. The government believes UHG had information about hundreds of thousands of invalid diagnoses that wrongfully entitled the insurer to higher payments. It also alleges UHG provided financial incentives for physicians to provide incorrect diagnoses that would result in higher reimbursements to the insurer.

More on the DOJ’s Position


The complaints filed in both of these qui tam lawsuits against UHG demonstrate why the government believes the insurer to be liable and how it could have avoided civil liability under the FCA. The DOJ alleges UHG is guilty of violating numerous provisions of the FCA regarding false claims, false statements, and reverse false claims. More specifically, the DOJ alleges UHG and its relevant groups:

  • Knew, or should have known by 2008, that they were required to take action to find and delete invalid codes submitted to them and to ensure the codes submitted to the Centers for Medicare and Medicaid Services (CMS).
  • Knew or intentionally avoiding learning that some diagnoses codes or categories of codes submitted to their plans by providers were invalid despite acknowledging in 2010 that it should evaluate the results of its blind chart reviews to find codes that need to be deleted.
  • Did not follow up on and prevent the submissions of invalid codes or submit deletion for invalid codes.
  • Attested to CMS each year that the data they submitted was true and accurate while knowing it was not.

What Happens Next?


Now that the DOJ has intervened in these qui tam suits and filed complaints regarding the government’s arguments, the court awaits the defendants’ responses. A response is due in the Swoben case by July 14, 2017 and in the Poehling case by July 17, 2017.

Do You Have Information About Fraud in the Health Care Industry?

The U.S. health care industry is rife with fraud against the federal and states governments. If you have any information regarding these actions, contact a California qui tam attorney from Brod Law Firm at (800) 427-7020 to schedule a free consultation.

(image courtesy of Jimi Filipovski)

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