In March, 2017, we told you about a qui tam whistleblower case brought against United Healthcare and other insurance companies that the U.S. Department of Justice (DOJ) decided to join after a five-year investigation. The allegations, which run into hundreds of millions of dollars, involve the Medicare Advantage program. United Health is the largest provider of Medicare Advantage plans.
Now the whistleblower, Benjamin Poehling, who has been characterized as a “former well-placed official” at UnitedHealth Group, has gone public with allegations that the big health insurance corporations have been swindling the Medicare Advantage program since it began almost 15 years ago. In an interview, Poehling said, “They’ve set up a perfect scheme here. It was rigged so there was no way they could lose.”
How Do Medicare and Medicare Advantage Differ?
With traditional Medicare, medical professionals are directly reimbursed for visits and procedures. Because this fact has often tempted the less-than-honest into persuading patients to undergo unnecessary procedures, Medicare Advantage was created in an effort to control costs.
Under Medicare Advantage, the government enters into contracts with insurance companies to manage Medicare expenses. The insurance companies receive an annual payment from Medicare for each individual the company signs up. Additional payments are made for patients who receive treatment for a number of medical conditions, such as diabetes. It is the private insurance company that reimburses the medical professional for a Medicare Advantage patient, not Medicare.
However, the flaw with Medicare Advantage is that the insurance companies have an incentive to find certain illness diagnoses in their customers to gain larger payments. Therefore, diagnoses may be enlarged upon; diabetes without complications can become diabetes with complications in order to get paid more.
Poehling (the whistleblower) went into great detail with his allegations concerning how UnitedHealth, as well as other insurers—in his opinion—bilked the system. UnitedHealth supposedly operated projects that were intended to make patients appear sicker than they actually were, in order to receive greater payments, by manipulating diagnostic codes for the illnesses. (All payments to insurers are based on diagnostic codes.) People like him who worked as finance directors, Poehling claimed, were paid bigger bonuses for finding ways to tweak the codes.
A Second Case Joined by the DOJ
The Department of Justice decided to join another case brought by a whistleblower against UnitedHealth. In the second case, it is alleged that UnitedHealth had false information related to patient health problems that could have been corrected, and received higher payments based on the false information. Federal prosecutors want to combine both cases into one.
In a 2016 report by the U.S. Government Accountability Office, it was stated that approximately $14.1 billion was paid improperly by the Centers for Medicare & Medicaid Services to Medicare Advantage insurance plans during 2013. In a 2014 estimation done by the Center for Public Integrity, researchers calculated that around $70 billion in improper payments were made between 2008 and 2013 by the government to Medicare Advantage insurers.
UnitedHealth has issued at least two statements asserting it is “confident” it was in compliance with Medicare regulations.
Working with whistleblowers tirelessly to shed light on fraudulent practices
If you think you have the facts needed to bring a whistleblower case, the experienced whistleblower attorneys at the Louthian Law Firm can review your case and help you file the appropriate disclosure statement. Under some circumstances, the government will intervene, or join in your lawsuit.
Your chances of succeeding are greater if your whistleblower claim is substantive, clear, and to the point. Because of this, meeting with a qualified whistleblower attorney can increase your chances of winning. The Louthian Law Firm can help you form your claim so that the government will be more inclined to intervene in your case; government intervention can sometimes increase the chances of recovering reward money. Even if the government decides not to intervene, it could still be a good idea to pursue your case without government involvement. Our strong support system can assist you through every step of the process.
For a free, confidential evaluation of your case, call the Louthian Law Firm today at 1-803-454-1200 or, if you prefer, you can fill out our online contact form.