The Justice Division’s years-long court docket battle to power 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 didn’t 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 had been to illegally pocket greater than $2 billion in overpayments.
“A mere risk of an overpayment shouldn’t 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, will 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 various to the standard 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 had been overpaid or that we did something flawed,” UnitedHealth spokesperson Heather Soule mentioned in a press release.
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 greater charges to cowl sicker sufferers however requires that their circumstances be correctly documented in medical information.
The DOJ alleges Medicare paid UnitedHealth Group greater than $7.2 billion from 2009 by 2016 based mostly 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 response to 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 opinions, the medical insurance big ignored overcharges which may have decreased payments.
However the particular grasp, who was appointed by U.S. District Decide Fernando Olguin, concluded the federal government’s case “relies upon completely 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 lawyer who represented a special whistleblower in one of many earliest instances alleging billing fraud by a Medicare Benefit insurance coverage firm. Hanagami mentioned he expects the federal government to enchantment the choice.
Segal famous that UnitedHealth executives informed Facilities for Medicare & Medicaid Providers officers about its chart evaluation insurance policies at an April 2014 assembly. On the time, CMS was contemplating a regulation to limit use of chart opinions, however the company backed off the regulation beneath stress from the insurance coverage trade. On the time, a CMS official described the trade’s response as an “uproar.”
The particular grasp famous that United had requested the assembly with CMS officers, which she referred to as “the alternative of concealment.”
“The issue with the federal government’s allegations is that the federal government knew of the very chart evaluation practices which it now claims United prevented it from studying, and thus the federal government can not 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 had 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 evaluation.
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 trade has been the goal of dozens of whistleblower lawsuits and authorities audits alleging that the plans price taxpayers an excessive amount of cash, together with a demand final month by Senate Judiciary Committee chair Chuck Grassley (R-Iowa) that UnitedHealth clarify its billing practices.
