UnitedHealth Group is again responding to a Wall Street Journal story about billing practices for its Medicare Advantage plan.
The Department of Justice’s criminal healthcare-fraud unit is investigating how UnitedHealth Group is deploying doctors and nurses to gather diagnoses that bolster its payments, The Wall Street Journal reported on Wednesday.
WHY THIS MATTERS
The investigation dates back to at least last summer, the WSJ said, but new details are emerging. Former UnitedHealth employees have been questioned by prosecutors, with the FBI and the Department of Health and Human Services’ Office of Inspector General also participating in some of the interviews, the report said.
The former employees reportedly told investigators about UnitedHealth’s efforts to encourage the documentation of certain lucrative diagnoses, including testing patients, implementing procedures to ensure that medical conditions were captured and sending nurses to patients’ homes.
In a statement also published on Wednesday, UnitedHealth fought back.
“We stand firmly behind the integrity of our Medicare Advantage business and the positive impact it delivers to millions of seniors across the country. As an important public sector partner serving people’s health needs, we expect and welcome regular reviews of our policies and practices. Our operations are governed by strict federal regulations and subject to rigorous oversight, driving transparency and compliance with CMS requirements."
Independent Centers for Medicare and Medicaid audits confirm UnitedHealth is among the most accurate in the industry for its coding practices, the company said.
“Additionally, after more than a decade of a similar Department of Justice challenge to our Medicare Advantage business, the Special Master concluded there was no evidence to support the claims that we were overpaid or engaged in any wrongdoing,” UnitedHealth said.
Recently, the company announced it would deploy a regular, independent third-party coding oversight and audit process to supplement its existing quality assurance program.
Today, The Wall Street Journal ran a story about how the big MA insurers such as UnitedHealth and Humana are being squeezed between rising costs and decreasing government payments.
THE LARGER TREND
“Today’s article from The Wall Street Journal represents a continuation of its sustained campaign against Medicare Advantage, relying on incomplete data, a predetermined narrative and a flawed understanding of how the Medicare Advantage program works,” UnitedHealth said in its July 9 statement.
On Dec. 30, former CEO Andrew Witty responded to what he called "misleading" articles published in The Wall Street Journal around Medicare Advantage plans.
"In a series of misleading articles, the Wall Street Journal has waged a one-sided, biased attack on Medicare Advantage (MA) – a program millions of seniors rely on for healthcare," Witty said. "The narratives woven through the articles rely on often incomplete and inaccurate data to conduct flawed studies through a murky government 'agreement,' and clearly demonstrate that the Journal does not understand the Medicare Advantage program, how it is designed to function or why it differs from the traditional fee-for-service program which emphasizes volume over quality and patient outcomes."
The company had been playing defense since the backlash of consumer complaints against the health insurance industry and specifically the country’s largest health insurer, following the fatal shooting of UnitedHealthcare executive Brian Thompson on Dec. 4, 2024.
Luigi Mangione, who has been charged with first degree murder of Thompson, carried a manifesto against corporate America and its profits.
Email the writer: SMorse@himss.org