UnitedHealth Notches ‘Symbolic Win’ for Medicare Advantage Industry on Chart Reviews
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Mar 06, 2025
After more than a decade of fighting False Claims Act allegations regarding its use of chart reviews to find additional diagnoses for risk adjustment purposes, UnitedHealth Group this week notched a major win with a recommendation from a retired judge, who was appointed by a federal court to weigh in on the longstanding case. The order, if followed by the U.S. District Court for the Central District of California, could have important implications for so-called “one-sided” chart reviews — in which insurers like UnitedHealthcare seek additional codes that doctors may have failed to include in submitting claim forms — and the question of whether those reviews should also be used to verify previously submitted codes.
The case (U.S. ex rel. Benjamin Poehling v. UnitedHealth Group, Inc.,16-08697) dates to 2011, when whistleblower Benjamin Poehling filed a civil fraud complaint against his former employer. The Dept. of Justice (DOJ) intervened in 2017, and it amended its complaint-in-intervention in 2018 after a California federal judge dismissed the government’s claims targeting the insurer’s alleged submission of false Risk Adjustment Attestations. At the time, the judge said the government could proceed with its allegations that UnitedHealth failed to remove invalid diagnoses when submitting claims for risk-adjusted payments to the government.
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