Massachusetts Attorney General Andrea Joy Campbell is suing UnitedHealthcare, alleging that the insurance giant “manipulated the health status” of Medicaid members to secure higher payments.
Campbell’s office said the insurer’s actions likely defrauded the state’s Medicaid program, MassHealth, of at least $100 million.
MassHealth members who choose a Senior Care Options (SCO) plan must receive a health evaluation that determines their health status and assigns them to one of three levels of care, with level one being the least serious and level three being the most serious.
Campbell alleges that UnitedHealthcare introduced assessments for members that placed them in tier two, which is for members with behavioral health or substance abuse issues. The insurer would assign diagnoses such as depression or anxiety to these members, even if they lacked a corresponding diagnosis or treatment, according to the lawsuit.
The attorney general also claims that UnitedHealthcare incorrectly assessed SCO members as having conditions that would place them in level three, indicating they have serious, chronic health needs. The insurer learned of this through internal reviews in 2018 and 2019, but did not disclose the findings to MassHealth or refund the misdistributed funds, according to the lawsuit.
Additionally, the lawsuit alleges that UHC would bill MassHealth for SCO members it said needed daily skilled nursing care, even if they did not need or receive those services.
The AG notes that UnitedHealthcare is the largest provider of SCO plans in the state.
“State managed care plans must act in good faith on behalf of their members and the financial resources of our state’s Medicaid program,” Campbell said in an advertisement. “Our investigation found that UnitedHealthcare knowingly violated these obligations by manipulating health assessments to increase its profits.”
“This lawsuit sends a clear message that no business is above the law, and my office will hold businesses accountable for exploiting vulnerable residents and misappropriating taxpayer dollars,” Campbell said.
In a statement to Fierce Healthcare, UnitedHealthcare said the lawsuit is “baseless and does not accurately describe our Senior Care Options program, which helps seniors with complex care needs meet their individual health needs.”
“The Attorney General is simply wrong to say that Massachusetts seniors with complex care needs should not receive the support and services that UnitedHealthcare is helping to provide,” the company spokesperson said. “We remain focused on working with our state partner to help our members live healthier lives.”
