A court-appointed special master has recommended the dismissal of a 14-year-old whistleblower lawsuit against UnitedHealth Group, citing insufficient evidence to support the claims. The lawsuit, filed by former UnitedHealth finance director Benjamin Poehling in 2011, alleged that the company improperly collected billions of dollars by manipulating risk-adjustment payments in the Medicare Advantage program. Special Master Suzanne Segal found that the government failed to provide evidence to back up its accusations.
“The government needed to present evidence from which a jury could reasonably conclude that the diagnosis codes United submitted were invalid, i.e., that codes were not supported by the related medical record,” Segal wrote. “The complete failure of any evidence on this essential element must result in summary judgment for United.”
The Justice Department has stated that it objects to Segal’s report and recommendation, which has yet to be adopted by the judge overseeing the case. UnitedHealth Group maintains that its business practices are transparent, lawful, and approved by the federal agency responsible for Medicare.
“After more than a decade of DOJ’s wasteful and expensive challenge to our Medicare Advantage business, the special master concluded there was no evidence to support the DOJ’s claims we were overpaid or did anything wrong,” the company said in a statement.
Court recommends dismissal of lawsuit
The original whistleblower complaint named 15 health care companies, but the government narrowed its focus to UnitedHealth Group and WellMed, a Texas-based medical group acquired by UnitedHealth over a decade ago, in 2017.
Segal highlighted that the government’s arguments were speculative and lacked supporting evidence. She noted that the government assumed unsupported doctor diagnosis codes based on company coder reviews, without proving that the codes were erroneous. “Undisputed testimony confirmed that coders may themselves miss diagnosis codes supported by a medical record for any number of reasons,” Segal added.
She concluded, “This litigation has been pending for more than a decade, and the government has had ample opportunity to develop evidence in support of its theories. It has not done so.”
The case represents a significant setback for the government’s efforts to combat alleged overbilling in the Medicare Advantage industry. The ruling is not final, as the Justice Department has the opportunity to appeal the decision.
The outcome of this case could have far-reaching implications for the future of Medicare Advantage oversight and the government’s ability to pursue similar cases against other health care companies.
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