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 that the insurer’s actions likely defrauded the state’s Medicaid program, MassHealth, of at least $100 million.
MassHealth enrollees who choose a Senior Care Options (SCO) plan are required to receive a health assessment 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 as the most serious.
Campbell alleges that UnitedHealthcare submitted assessments for members that placed them in level two, which is for members with behavioral health or substance abuse conditions. The insurer would assign diagnoses like 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 improperly assessed SCO members as having conditions that would place them in level three, indicating they have serious, chronic health needs. The insurer was made aware of this through internal reviews in 2018 and 2019, but did not disclose the findings to MassHealth or repay the improperly dispersed funds, according to the lawsuit.
In addition, the lawsuit alleges that UHC would bill MassHealth for SCO members that it said needed daily skilled nursing care, even if they did not need or receive those services.
The AG notes that UnitedHealthcare is the state’s largest provider of SCO plans.
“The state’s managed care plans need to act in good faith on behalf of their members and the financial resources of our state’s Medicaid program,” Campbell said in an announcement. 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 company is above the law, and my office will hold companies accountable for exploiting vulnerable residents and misusing taxpayer dollars,” Campbell said.
In a statement to Fierce Healthcare, UnitedHealthcare said the lawsuit is “meritless and doesn’t accurately describe our Senior Care Options program, which helps seniors with complex care meet their individual health needs.”
“The Attorney General is simply wrong that Massachusetts seniors with complex care needs should not be receiving the support and services UnitedHealthcare is helping to provide,” the company’s spokesperson said. “We remain focused on working with our state partner to help our members live healthier lives.”
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