The Justice Division’s years-long court docket battle to pressure UnitedHealth Group to return billions of {dollars} in alleged Medicare Benefit overpayments hit a serious setback Monday when a particular grasp dominated the federal government had did not show its case.
Find for UnitedHealth, Particular Grasp Suzanne Segal discovered that the DOJ had not introduced proof to assist its declare that the enormous well being insurer exaggerated how sick sufferers have been to illegally pocket greater than $2 billion in overpayments.
“A mere risk of an overpayment will not be sufficient for the federal government to hold its burden,” Segal wrote in an preliminary ruling. She advisable that UnitedHealth’s movement to dismiss the case be granted. The advice, which is to be introduced to the federal choose dealing with the case, might be appealed inside two weeks.
The civil fraud case towards UnitedHealth Group, the nation’s largest Medicare Benefit insurer, was filed in 2011 by whistleblower Benjamin Poehling, a former firm worker. The DOJ took over the case in 2017. Medicare Benefit is the privately run different to the normal Medicare program for seniors.
“After greater than a decade of DOJ’s wasteful and costly problem to our Medicare Benefit enterprise, the Particular Grasp concluded there was no proof to assist the DOJ’s claims we have been overpaid or that we did something unsuitable,” UnitedHealth spokesperson Heather Soule mentioned in an announcement.
Wyn Hornbuckle, a spokesperson for the Justice Division, mentioned the company wouldn’t touch upon the ruling, which was filed in federal court docket in Los Angeles. Attorneys for whistleblower Poehling had no remark.
Medicare pays Benefit well being plans increased charges to cowl sicker sufferers however requires that their situations be correctly documented in medical information.
The DOJ alleges Medicare paid UnitedHealth Group greater than $7.2 billion from 2009 by 2016 primarily based on the corporate’s efforts to spice up income by reviewing affected person information to search out further diagnoses and including medical billing codes to their recordsdata. In accordance with the DOJ, Medicare would have paid the corporate $2.1 billion much less if it had deleted unsupported billing codes.
The Justice Division additionally alleged that in these chart evaluations, the medical health insurance large ignored overcharges which may have lowered payments.
However the particular grasp, who was appointed by U.S. District Choose Fernando Olguin, concluded the federal government’s case “relies upon fully on hypothesis and assumptions about what the codes discovered by the United coders truly imply.”
“If this stands, I feel it’s a main defeat for the federal government,” mentioned William Hanagami, an legal professional who represented a unique whistleblower in one of many earliest circumstances alleging billing fraud by a Medicare Benefit insurance coverage firm. Hanagami mentioned he expects the federal government to attraction the choice.
Segal famous that UnitedHealth executives instructed Facilities for Medicare & Medicaid Companies officers about its chart evaluate insurance policies at an April 2014 assembly. On the time, CMS was contemplating a regulation to limit use of chart evaluations, however the company backed off the regulation beneath strain from the insurance coverage business. On the time, a CMS official described the business’s response as an “uproar.”
The particular grasp famous that United had requested the assembly with CMS officers, which she known as “the alternative of concealment.”
“The issue with the federal government’s allegations is that the federal government knew of the very chart evaluate practices which it now claims United prevented it from studying, and thus the federal government can’t have been duped into counting on any motion or inaction by United in figuring out whether or not it had been the sufferer of overpayments,” Segal wrote.
Segal famous CMS audits of UnitedHealth’s Medicare Benefit plans had discovered that about 89% of billing codes have been supported by affected person medical information. The audit findings “undercut” the federal government’s declare that the corporate engaged in widespread overbilling.
“This litigation has been pending for greater than a decade,” she wrote, “and the federal government has had ample alternative to develop proof in assist of its theories. It has not.”
The choice comes as UnitedHealth faces renewed investigations into its dealing with of Medicare Benefit coding, together with a brand new Justice Division evaluate.
Medicare Benefit insurance coverage have grown explosively in recent times and now enroll about 33 million members, greater than half of individuals eligible for Medicare.
The business has been the goal of dozens of whistleblower lawsuits and government audits alleging that the plans price taxpayers an excessive amount of cash, together with a demand last month by Senate Judiciary Committee chair Chuck Grassley (R-Iowa) that UnitedHealth clarify its billing practices.
