Massachusetts Attorney General Andrea Joy Campbell sued UnitedHealthcare on Friday, alleging the insurer “falsely manipulated” the health status of MassHealth members enrolled in the Senior Care Options plan in order to receive higher payments from the government.
MassHealth is the Medicaid program of Massachusetts. The Senior Care Options (SCO) program supports members 65 or older living in designated areas of the state, and UnitedHealthcare is the largest provider of SCO plans in Massachusetts.
Enrollees of the SCO program have to receive an in-home clinical assessment to determine their health status. They are then assigned one of three levels of care, with level 1 being the least serious with the lowest payment rate, and level 3 being the most serious with the highest payment rate.
Campbell alleges UnitedHealthcare defrauded MassHealth of at least $100 million in three ways:
- Submitting assessments of members in the United SCO plan that gave them a level 2 classification, which is intended for those with behavioral health or substance use disorders. However, these members did not have a diagnosis or treatment associated with these conditions.
- Improperly assessing members in the SCO plan with conditions leading to level 3 classifications, even though they did not qualify for level 3 services.
- Submitting assessments to MassHealth that stated certain members required daily skilled nursing services even though most did not receive or need that level of care, leading to inflated payments.
“The state’s managed care plans need to act in good faith on behalf of their members and the financial resources of our state’s Medicaid program. Our investigation found that United Healthcare knowingly violated these obligations by manipulating health assessments to increase its profits,” Campbell said in a statement. “This lawsuit sends a clear message that no company is above the law, and my office will hold companies accountable for exploiting vulnerable residents and misusing taxpayer dollars.”
The Attorney General’s office also alleges that UnitedHealthcare’s actions were part of a “growth at all costs” strategy, which incentivized and encouraged its field nurses to code MassHealth members as sicker than they were.
“United relentlessly pursued a growth-at-all-costs strategy that failed to allocate resources to ensure that it accurately reported members’ conditions to MassHealth,” the complaint stated. “United chronically understaffed the nurses who were responsible for assessing members as part of the United SCO Plan and created an incentive structure in which United’s overworked nurses would not have to complete as many member assessments if they represented that the members had more serious health conditions, even if those members did not.”
A spokesperson for UnitedHealthcare called the lawsuit “meritless.”
“[The complaint] doesn’t accurately describe our Senior Care Options program, which helps seniors with complex care meet their individual health needs,” the spokesperson said. “The Attorney General is simply wrong that Massachusetts seniors with complex care needs should not be receiving the support and services UnitedHealthcare is helping to provide. We remain focused on working with our state partner to help our members live healthier lives.”
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