Healthcare Fraud: Up Next for DOJ
The Wall Street Journal’s article about a criminal healthcare investigation of United Health by DOJ’s Healthcare Fraud Section signals renewed emphasis on corporate healthcare investigations and continued scrutiny of Medicare Advantage programs.
United Health: Medicare Advantage
The article highlights how DOJ Fraud is investigating United Health’s Medicare Advantage business practices for potential healthcare fraud.
First, any corporate healthcare fraud investigation centers around the federal healthcare fraud statute: 18 U.S.C. § 1347.
On a high level, this statute criminalizes a “scheme to defraud” which is generally defined as “means any plan, pattern, or course of action involving a false or fraudulent pretense, representation, or promise intended to deceive others in order to obtain something of value, such as money, from the institution to be deceived.”
In the healthcare context, this statute requires proof that an individual acted with the intend to defraud by submitting false claims to Medicare for payment for claimed medical services.
Second, the healthcare fraud statute covers false claims submitted to Medicare as part of Medicare Advantage.
Medicare Advantage is a bundled coverage option for Medicare beneficiaries. In other words, Medicare beneficiaries can sign up for a Medicare Advantage plan with a private insurer, like UnitedHealth, and obtain medical, dental, and hospital coverage in one health insurance plan.
The pros of such a plan are efficiency for the beneficiary; he cons are limited provider options.
What’s the healthcare fraud angle?
If past is prologue (and it often is with indictments), prosecutors at DOJ’s Fraud Section may be looking at efforts by UnitedHealth insiders to falsify patient records (1) by stuffing patient files with fake diagnoses for Medicare beneficiaries so that the beneficiaries look more sick (2) all so that Medicare would pay more to United Health’s Medicare Advantage Program.
In 2023, DOJ’s Fraud Section charged an individual who oversaw HealthSun’s Medicare Advantage Program. That individual was charged with conspiracy to commit healthcare fraud, wire fraud, and major fraud against the United States.
That case is set for trial this summer in Miami (SDFL).
The gist of the indictment was that the individual caused false information about beneficiaries’ health to be entered into HealthSun’s internal medical records. In essence, the goal of the charged scheme was to make the beneficiaries look more sick on paper (through falsified conditions and diagnoses) so that Medicare would pay more money to HealthSun.
The money adds up quickly. The charged healthcare scheme in the HealthSun indictment resulted in tens of thousands of falsified diagnoses, and Medicare overpaying HealthSun millions of dollars.
