The Justice Department’s years-long court docket battle to power UnitedHealth Group to return billions of {dollars} in alleged Medicare Advantage overpayments hit a serious setback Monday when a particular grasp dominated the federal government had did not show its case.
In discovering for UnitedHealth, Special Master Suzanne Segal discovered that the DOJ had not introduced proof to help its declare that the large well being insurer exaggerated how sick sufferers had been to illegally pocket greater than $2 billion in overpayments.
“A mere possibility of an overpayment is not enough for the government to carry its burden,” Segal wrote in an preliminary ruling. She really helpful 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 in opposition to UnitedHealth Group, the nation’s largest Medicare Advantage insurer, was filed in 2011 by whistleblower Benjamin Poehling, a former firm worker. The DOJ took over the case in 2017. Medicare Advantage is the privately run different to the standard Medicare program for seniors.
“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 that we did anything wrong,” UnitedHealth spokesperson Heather Soule stated in an announcement.
Wyn Hornbuckle, a spokesperson for the Justice Department, stated 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 Advantage well being plans greater charges to cowl sicker sufferers however requires that their circumstances be correctly documented in medical data.
The DOJ alleges Medicare paid UnitedHealth Group greater than $7.2 billion from 2009 by way of 2016 primarily based on the corporate’s efforts to spice up income by reviewing affected person data to search out extra diagnoses and including medical billing codes to their information. According to the DOJ, Medicare would have paid the corporate $2.1 billion much less if it had deleted unsupported billing codes.
The Justice Department additionally alleged that in these chart critiques, the medical health insurance large ignored overcharges which may have lowered payments.
But the particular grasp, who was appointed by U.S. District Judge Fernando Olguin, concluded the federal government’s case “depends entirely on speculation and assumptions about what the codes found by the United coders actually mean.”
“If this stands, I think it is a major defeat for the government,” stated William Hanagami, an legal professional who represented a distinct whistleblower in one of many earliest instances alleging billing fraud by a Medicare Advantage insurance coverage firm. Hanagami stated he expects the federal government to attraction the choice.
Segal famous that UnitedHealth executives informed Centers for Medicare & Medicaid Services officers about its chart evaluation insurance policies at an April 2014 assembly. At the time, CMS was contemplating a regulation to limit use of chart critiques, however the company backed off the regulation beneath stress from the insurance coverage business. At 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 opposite of concealment.”
“The problem with the government’s allegations is that the government knew of the very chart review practices which it now claims United prevented it from learning, and thus the government cannot have been duped into relying on any action or inaction by United in determining whether it had been the victim of overpayments,” Segal wrote.
Segal famous CMS audits of UnitedHealth’s Medicare Advantage plans had discovered that about 89% of billing codes had been supported by affected person medical data. The audit findings “undercut” the federal government’s declare that the corporate engaged in widespread overbilling.
“This litigation has been pending for more than a decade,” she wrote, “and the government has had ample opportunity to develop evidence in support of its theories. It has not.”
The resolution comes as UnitedHealth faces renewed investigations into its dealing with of Medicare Advantage coding, together with a brand new Justice Department evaluation.
Medicare Advantage insurance policy have grown explosively lately 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 value 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.
Fred Schulte:
[email protected],
@FredSchulte
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