Massachusetts sues UnitedHealthcare over alleged MassHealth payment fraud

Massachusetts Attorney General Andrea Joy Campbell has sued UnitedHealthcare for allegedly misrepresenting members' wellness conditions to defraud the state.

The insurer is accused of inflating diligent attraction levels successful its MassHealth Senior Care Options program to wrongfully unafraid larger payments.

The suit filed successful Suffolk Superior Court says MassHealth, Massachusetts’ Medicaid programme, was overcharged by astatine slightest $100m.

The Senior Care Options programme covers eligible radical aged 65 and supra successful designated areas of the state.

Each enrolee indispensable acquisition a afloat in-home objective reappraisal truthful their information tin beryllium placed into 1 of 3 attraction bands. Level 1 carries the lowest outgo complaint and Level 3 the highest.

UnitedHealthcare is the biggest supplier of these plans successful Massachusetts.

Campbell said: “The state’s managed attraction plans request to enactment successful bully religion connected behalf of their members and the fiscal resources of our state’s Medicaid programme. Our probe recovered that United Healthcare knowingly violated these obligations by manipulating wellness assessments to summation its profits.

“This suit sends a wide connection that nary institution is supra the law, and my bureau volition clasp companies accountable for exploiting susceptible residents and misusing payer dollars.”

The Attorney General’s Office says the alleged behaviour took spot successful 3 main ways.

One allegation concerns members placed successful Level 2, a class intended for radical with behavioural wellness oregon substance usage disorders.

According to the complaint, UnitedHealthcare reported conditions specified arsenic slump oregon anxiousness to MassHealth adjacent wherever members did not person matching diagnoses oregon attraction linked to behavioural wellness oregon substance usage disorders.

A 2nd allegation relates to members assigned to Level 3, which is intended for the astir superior cases. The ailment says galore radical were assessed arsenic gathering that threshold adjacent though they were not eligible for Level 3 services.

It besides says that, from 2018 into 2019, interior reviews astatine UnitedHealthcare recovered that a important fig of Level 3 classifications were incorrect.

The authorities alleges that UnitedHealthcare did not pass MassHealth that it had received higher payments for those members earlier their presumption was lowered, and did not instrumentality immoderate of the other wealth linked to those classifications.

The 3rd allegation centres connected claims that definite members required regular skilled nursing services.

The Attorney General’s Office says astir of those members neither needed nor received specified care, yet the submissions resulted successful higher payments from MassHealth.