The U.S. Department of Justice’s (DOJ) criminal healthcare-fraud unit has intensified its investigation into UnitedHealth Group Inc’s (NYSE:UNH) Medicare billing practices, focusing on how it leveraged doctors and nurses to boost government payments.
The probe began at least a year ago and is now drawing fresh scrutiny as former employees speak with federal investigators.
The Wall Street Journal reported that former UnitedHealth employees told investigators that the company encouraged the capture of certain lucrative diagnoses during patient assessments.
Also Read: Humana Backs Reforms To Limit Medicare Advantage Billing Practices
These efforts included testing patients, implementing protocols to document medical conditions, and dispatching nurses to conduct in-home evaluations.
In May, UnitedHealth was reportedly investigated by the DOJ for possible Medicare fraud. The company then said, “We have not been notified by the Department of Justice of the supposed criminal investigation reported, without official attribution, in the Wall Street Journal today.”
“We stand by the integrity of our Medicare Advantage program,” the company statement continued. One focal point of the investigation is UnitedHealth’s HouseCalls unit, which sends nurses to Medicare members’ homes.
Nurses use software that prompts them to record potential diagnoses during these visits. Investigators questioned a former nurse practitioner from the unit.
They probed using specific tools, such as the QuantaFlo device, which helps detect peripheral artery disease, a diagnosis flagged in a Wall Street Journal analysis for its frequent use.
Investigators are also reviewing UnitedHealth’s internal software feature called the “diagnosis cart,” which displays possible conditions based on the nurse’s inputs. Among the diagnoses under scrutiny are peripheral artery disease and secondary hyperaldosteronism, both of which can lead to higher Medicare payments.
UnitedHealth has said that its healthcare professionals are expected to rely on their clinical judgment when assigning diagnoses.
However, the Wall Street Journal’s reporting highlighted that the company’s Medicare Advantage members received high-paying diagnoses more often than those enrolled in competing plans, potentially resulting in billions of dollars in extra taxpayer-funded payments.
Between 2019 and 2021, UnitedHealth received an average of $2,735 in additional payments per nurse home visit based on new diagnoses, roughly 50% more than the industry average.
In 2021 alone, the insurer collected $8.7 billion in payments for diagnoses that were not backed by treatment claims from doctors or hospitals, accounting for nearly half of such payments made that year.
The Journal also found that doctors employed by UnitedHealth’s medical practices assigned certain high-value diagnoses at abnormally high rates.
Stephen Hemsley, recently appointed CEO, is stepping forward to acknowledge the fallout and chart a new course, promising a comprehensive review of some of the company’s most controversial practices.
In July, the DOJ charged over 320 individuals, uncovering nearly $15 billion in fraudulent claims, marking a significant milestone in the fight against healthcare fraud.
The department revealed a staggering $14.6 billion in fraudulent claims. The operation, named “Operation Gold Rush,” also resulted in the seizure of assets worth over $245 million, including cash, luxury vehicles, and cryptocurrency.
Price Action: UNH stock is down 1.87% at $301.94 during the premarket session at last check Wednesday.
Read Next:
- Alibaba Predicts AI Digital Colleagues Will Be Commonplace Within Five Years
Photo by Piotr Swat via Shutterstock
