The Justice Division’s years-long court docket battle to pressure 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.
To find for UnitedHealth, Particular Grasp Suzanne Segal discovered that the DOJ had not introduced proof to assist 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 risk of an overpayment just isn’t sufficient for the federal government to hold its burden,” Segal wrote in an preliminary ruling. She really useful 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 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 different 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 incorrect,” UnitedHealth spokesperson Heather Soule stated in an announcement.
Wyn Hornbuckle, a spokesperson for the Justice Division, 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 Benefit 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 via 2016 primarily based on the corporate’s efforts to spice up income by reviewing affected person data to seek out further diagnoses and including medical billing codes to their information. Based on 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 evaluations, the medical health 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 fully on hypothesis and assumptions about what the codes discovered by the United coders really imply.”
“If this stands, I feel it’s a main defeat for the federal government,” stated William Hanagami, an legal professional who represented a distinct whistleblower in one of many earliest instances alleging billing fraud by a Medicare Benefit insurance coverage firm. Hanagami stated he expects the federal government to attraction the choice.
Segal famous that UnitedHealth executives instructed Facilities for Medicare & Medicaid Providers officers about its chart overview insurance policies at an April 2014 assembly. On the time, CMS was contemplating a regulation to limit use of chart evaluations, however the company backed off the regulation below strain 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 other of concealment.”
“The issue with the federal government’s allegations is that the federal government knew of the very chart overview 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 data. 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 overview.
Medicare Benefit insurance policy 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 value 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.
