The U.S. Justice Department has joined another whistle-blower lawsuit against UnitedHealth Group that alleges the insurer fraudulently billed the Medicare program by claiming patients were sicker than they were.
The lawsuit, initially filed in 2009 by whistle-blower James Swoben, alleges the Minnetonka, Minn.-based insurer inflated its plan members' risk scores in order to boost payments under Medicare Advantage's risk-adjustment program.
The Justice Department joined a similar lawsuit last month and sought an order on Monday to combine the two cases.
UnitedHealth, the nation's largest Medicare Advantage insurer, allegedly collected payments from false claims that it treated patients for conditions they didn't have, for more severe conditions than they had, conditions that had already been treated, or diagnoses that didn't meet the requirements for risk adjustment.
The other lawsuit, filed in 2011, alleges similar claims. That suit alleges that in 2010, UnitedHealth planned to increase operating income by $100 million through "Project 7," which was the company's codeword for initiatives to increase risk-adjustment payments.
Under the Medicare Advantage program, the government pays private health plans monthly amounts for every member they cover, and those taxpayer-funded payments are adjusted based on how sick someone is.
Members with more chronic conditions have higher risk scores, and plans that cover them receive higher payments. These risk scores were created to incentivize plans to cover all seniors regardless of their health status, but there have been several whistle-blower lawsuits in recent years that allege health plans have been inflating the scores to collect more funds.
