Whistleblower Says Major Insurers Defrauded Government

August 11, 2016. On Wednesday the U.S. Court of Appeals for the Ninth Circuit reversed a lower court’s dismissal of a False Claims Act case against several of the nation’s largest health insurers. The Court ruled that the whistleblower, James Swoben, put forward enough evidence to suggest that insurers like HealthCare Partners, UnitedHealthCare and Aetna have violated the False Claims Act by manipulating their reporting of patient health data in order to get larger government payment.

Swoben alleged that the defendant insurers had submitted false certifications in violation of the False Claims Act. In holding that Swoben alleged “a cognizable legal theory” under the FCA, the Court stated that the Insurers had “an obligation to undertake ‘due diligence’ to ensure the accuracy, completeness, and truthfulness” of the risk adjustment data,” of which there is evidence they failed.

Related links:

• The decision of the Court of Appeals
• Article in National Law Journal. Health Insurers Lose Appeal in False-Claims Suit Over One-Sided Reviews
• Article in Insurance Business America. Whistleblower: Major insurers fleeced government for at least $1 billion