Last year, DOJ intervened in United States ex rel. Poehling v. UnitedHealth Group., Inc. (C.D. Cal.). In this case, DOJ alleged FCA violations relating to Medicare Advantage “risk adjustment” scores. Risk adjustment alters payments to MA plans to reflect expected costs associated with the health status of Medicare beneficiaries enrolled in MA plans.
In a ruling on a motion to dismiss in February 2018, the presiding judge in Poehling dismissed allegations that UnitedHealth had falsely attested to the accuracy of the risk adjustment scores. The judge allowed the case to proceed on a theory that the defendant had improperly avoided an obligation to refund the government for risk-adjustment related overpayments.
Poehling is one of several pending cases brought by DOJ and relators in district courts across the country in which MA plans are defendants.
Practice Note: DOJ’s intervention in Poehling reflects a shift towards government enforcement against MA plans. With enrollment in MA plans steadily increasing, it is likely that this trend will continue. We will continue to monitor Poehling and other cases pending in district court and report back in subsequent roundups.