The ever-increasing costs of healthcare and access to needed medical treatment for people who have serious medical issues have been hot-button topics across the country for many years. The Department of Justice has joined two lawsuits that were originally filed by whistleblowers. The lawsuits say that UnitedHealth Group inflated risk scores for patients enrolled in the insurer’s Medicare Advantage program. Sources say that damages in the cases could exceed $1 billion – that is taxpayer money.
The whistleblowers, and now the federal government, believe that UnitedHealth intentionally overbilled Medicare by making patients look sicker than they really were to increase company profits. In 2003, the Centers for Medicare and Medicaid Services modified its reimbursement schedules to allow what is known as a risk adjustment factor.
The hope was that private managed care plans would sign up more unhealthy people, increasing access to medical care for many people who really need care, especially the elderly. Unfortunately, these HMOs and other private healthcare plans were given a new source of revenue for medical services.
Before the risk adjustment factor was announced, HMOs essentially received Medicare reimbursements at a fixed rate. The government provided a new method for managed care insurance providers to receive additional revenues for managed care programs that provided services to people with complex health conditions. Unfortunately, many believe that the risk adjustment factor program provided a new incentive for managed care plans to seek more and more reimbursements, with the real risk for fraud.
Whistleblower lawsuits provide a positive mechanism to uncover potential fraud. Whistleblowers are able to file a lawsuit on behalf of the government to correct fraudulent billing practices. The whistleblower is generally intended to a finder’s fee – that is to receive a percentage of any settlement or verdict that results from the lawsuit. The False Claims Act also provides individuals who come forward with legal protections against retaliation for bringing to light fraud against the government.