United Healthcare Services Inc., which operates the country’s largest private Medicare Advantage insurance plan (covering about 3.6 million people), has been accused by some of its own sales agents of concealing hundreds of complaints of enrollment fraud and other misconduct. The company is currently embroiled in an earlier lawsuit, filed in May, accusing it of overbilling federal health care programs to the tune of $1 billion by editing patient records to indicate that they were sicker than they actually were, thus generating additional revenue for the company via government payments.
In the recently unveiled whistleblower suit, filed in federal court in Wisconsin in the fall of 2016 and unsealed last week, United Healthcare is accused of keeping a “dual set of books,” the purpose of which was to hide complaints about its services. The whistleblowers also allege that investigations into the complaints that were actually acknowledged were “intentionally ineffective.”
The two whistleblowers, a United Healthcare sales agent and sales manager, respectively, accuse United Healthcare of hiding misconduct complaints from the Centers for Medicare & Medicaid Services (CMS) in order to avoid jeopardizing the company’s high rankings on the government’s quality ratings scales. The rankings are the basis on which the government pays out bonuses for “high quality” plans. Lots of money is at stake in the bonus program. The government paid United Healthcare bonuses totaling $1.4 billion in 2016. CMS relies on health plans to self-report and does not investigate the reports for accuracy.
According to the complaint, the “duel set of books” maintained by United Healthcare included one that was accurate, containing a complete list of complaints, along with details of the alleged misconduct, while the other set of books contained truncated and incomplete versions of the complaints. It was the second set of books that was provided to CMS. In addition, complaints were minimized, with many of the more serious allegations, including the forging of signatures on enrollment forms, listed as “inconclusive” or “unsubstantiated.”