Government Intervenes in Whistleblower’s False Claims Lawsuit Against UnitedHealth Group

Mary Jane Wilmoth

Published On: May 3rd, 2017

Monday, the Department of Justice announced it had intervened in a lawsuit against UnitedHealth Group (UHG) that alleges UHG obtained inflated risk adjustment payments based on untruthful and inaccurate information about the health status of beneficiaries enrolled in UHG’s largest Medicare Advantage Plan, UHC of California.

UHG, through more than 50 Medicare Advantage and Drug Prescription plans, receives a monthly payment from Medicare for each beneficiary that is based, in significant part, on the health status of the beneficiary.

The government’s complaint alleges that although UHG contractors conducted chart reviews for each beneficiary, it knowingly disregarded from these chart reviews about invalid diagnoses and thus avoided repaying Medicare monies to which it was not entitled.

“The intervention of the United States in this matter illustrates our commitment to ensure the integrity of the Medicare Part C program,” said Acting Assistant Attorney General Chad A. Readler of the Justice Department’s Civil Division.

The original lawsuit was filed by James Swoben, a former employee of Senior Care Action Network (SCAN) Health Plan and a consultant to the risk adjustment industry. The lawsuit was filed under the qui tam provisions of the False Claims Act, which permit private parties to sue on behalf of the United States for false claims for government funds, and to receive a share of any recovery. A qui tam plaintiff can receive between 15 and 30 percent of the total recovery from the defendant, whether through a favorable judgment or a settlement. The False Claims Act permits the government to intervene in such a lawsuit, as it has done, in part, in this case.