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United States Intervenes in Constantine Cannon Whistleblower’s suit against UnitedHealth Group, WellMed Medical Management

Posted  February 16, 2017

By the C|C Whistleblower Lawyer Team

The U.S. Department of Justice has joined Constantine Cannon in bringing a whistleblower’s False Claims Act lawsuit against UnitedHealth Group, the nation’s largest health insurer and largest operator of Medicare managed healthcare insurance plans. The suit alleges UnitedHealth and its various subsidiaries and affiliates defrauded Medicare by improperly inflating its risk adjustment reimbursement. The company’s fraudulent schemes allegedly cost taxpayers billions.

Medicare makes additional payments to managed-care plans like UnitedHealth based on plan members’ risk scores, which are calculated in part using patients’ medical diagnoses. Higher risk scores are assigned to patients with more costly-to-treat conditions, while those with less costly conditions receive lower scores. Ideally, risk-adjustment payments offset increased costs associated with treating sicker patients.

UnitedHealth allegedly overbilled the government by claiming its members were treated for conditions they either were not treated for or did not have, and for failing to correct previously submitted Medicare risk adjustment claims even though it knew, or should have known, that those claims were false.

One way UnitedHealth allegedly overstated its members’ risk scores was by combing through patient medical records for additional risk-adjusting diagnoses rather than “looking both ways” by also reviewing for previously submitted, unsupported diagnoses and deleting those invalid claims, as required by federal law. The suit says when UnitedHealth did audit its previously submitted claims, it found high error rates yet refused to take meaningful steps to identify and correct problems with the claims it submitted to Medicare.

The Department of Justice also joined in the whistleblower’s allegations against WellMed Medical Management, a Texas-based healthcare company UnitedHealth acquired in 2011, the suit claims, despite evidence WellMed was fraudulently overstating its risk scores.

The case, originally filed in 2011, had been kept under seal to allow the government time to investigate, and is now public due to the DOJ’s decision to intervene on the charges against UnitedHealth and WellMed. Allegations against thirteen additional defendants included in the whistleblower’s complaint have also been unsealed.

Tagged in: Government Decision, Managed Care, Medicare, Risk Adjustment Fraud, Upcoding, Whistleblower Case,


3 Replies to United States Intervenes in Constantine Cannon Whistleblower’s suit against UnitedHealth Group, WellMed Medical Management

  • Thank you. This comment was an attempt to cut down on healthcare fraud.

    If possible to receive reimbursement from those providers that committed fraud and malpractice when providing health care.

  • My health provision complaint filed with TDI went to Evercare then to United Health that illegally assessed my complaint. Fiduciary rules were breached.
    Providers filed against all has ownership or business associations with Evercare and UnitedHealthcare and think owned by United Health.
    A retrieved PHI included a false opiate assessment continuous and that denied offer of pain film.

  • Billy Leonard says:

    We need more whistleblowers to prove that we don’t and never have had free market healthcare. We need to join the rest of the modern world and have universal healthcare and stop all the fraud and thievery.

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