The legal battle of the Ministry of Justice to force Unitedhealth Group to return billions of allegedly allegedly attended dollars of Medicare Advantage succeeded a major setback on Monday when a special master judged that the government had not proven its case.
To note for Unitedhealth, the special master Suzanne Segal noted that the Doj had not presented evidence in support of his assertion that the giant insurer exaggerated how illustratedly pocket more than $ 2 billion in too many payments.
“A simple possibility of an overpayer is not enough for the government to carry its burden,” wrote Segal in an initial decision. She recommended that Unitedhealth’s request to reject the case to be granted. The recommendation, which must be presented to the federal judge dealing with the case, can be brought on appeal within two weeks.
The case of civil fraud against Unitedhealth Group, the largest medicare insurer of the country, was filed in 2011 by the denunciator Benjamin Poehling, a former employee of the company. The Doj take over The case in 2017. Medicare Advantage is the private alternative to the traditional Medicare program for the elderly.
“After more than a decade of unnecessary and expensive challenge of the Doj to our Medicare Advantage company, the special master concluded that there was no evidence to support the claims of the Doj that we were too paid or that we did something bad,” said the spokesman of Unitedhealth, Heather Soule, in a press release.
Wyn Hornbuckle, spokesperson for the Ministry of Justice, said the agency would not comment on the decision, which was filed before the Federal Court in Los Angeles. The lawyers for the Poehling denunciator had no comments.
Medicare pays advantageous health plans for higher rates to cover more sick patients, but requires that their conditions are properly documented in medical records.
The Doj alleys that Medicare paid Unitedhealth Group by more than $ 7.2 billion from 2009 to 2016 on the basis of business efforts to increase income by examining patient files to find additional diagnostics and add medical billing codes to their files. According to the doj, Medicare has paid the company 2.1 billion dollars less if it had suppressed the invoicing codes not taken care of.
The Ministry of Justice also alleged that in these graphic journals, the health insurance giant had ignored the overloads that may have reduced invoices.
But the special master, who was appointed by the American district judge Fernando Olguin, concluded that the government affair “depends entirely on speculation and hypotheses on what the codes found by the United Coders really mean”.
“If this is, I think it is a major defeat for the government,” said William Hanagami, a lawyer who represented a different denunciator in one of the first cases alleging the fraud billed by a Medicare insurance company Advantage. Hanagami said he would expect the government to appeal the decision.
Segal noted that the leaders of Unitedhealth informed the managers of Centers for Medicare & Medicaid Services regarding its graphic exam policies at a meeting in April 2014. At the time, CMS envisaged regulation to restrict the use of graphics exams, but the agency remote of the regulation under pressure from the insurance sector. At the time, a CMS official described the industry’s response as a “outcry”.
The special mastery noted that United asked for the meeting with CMS officials, which she called “the opposite of concealment”.
“The problem with the government’s allegations is that the government knew the review practices of the very cards which, according to which, prevented it from learning, and therefore the government cannot have been due to rely on an action or an inaction by determining if it had been the victim of Surpays,” wrote Segal.
Segal noted that the CMS audits of the Medicare Advantage plans of United have revealed that around 89% of the billing codes were supported by patient medical records. The results of the audit “undermine” the statement of the government according to which the company has embarked on a broad excess.
“This dispute has been pending for more than a decade,” she wrote, “and the government has had the opportunity to develop evidence in support of its theories. This is not the case. “”
The decision occurs while Unitedhealth faces Renewed surveys In its management of the Medicare Coding Advantage, including a new journal from the Ministry of Justice.
Medicare Advantage insurance regimes have grown explosively in recent years and now Register about 33 million membersMore than half of people eligible for health insurance.
Industry was the objective of dozens of prosecution against the denunciators and Government audits alleging that plans cost taxpayers too much money, including a Request last month By the president of the Senate judicial committee, Chuck Grassley (R-IOW), United explains his billing practices.
