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Justice Department sues UnitedHealth Medicare Advantage for fraud

Written by Diane Archer

At the end of March, the U.S. Justice Department joined a lawsuit brought by a whistleblower alleging that UnitedHealth Group committed fraud in its Medicare Advantage (commercial insurance that covers Medicare benefits) business. The charge is that UnitedHealth misrepresented the health status of its subscribers to Medicare in order to increase its Medicare payments.

Kaiser Health News reports that the breadth of UnitedHealth Group’s alleged fraud is significant. Damages could be more than $1 billion. That said, an investigation by the Center on Public Integrity suggests that fraud and overbilling by Medicare Advantage plans may be costing taxpayers tens of billions of dollars. The Government Accountability Office (GAO) has also reported on significant billing concerns with Medicare Advantage plans.

When Congress expanded Medicare to include commercial health plan options, the claim was that these plans could bring down Medicare costs significantly. In fact, these plans have restricted people’s choice of doctors and hospitals and driven up out-of-pocket costs significantly for people with complex conditions. In addition, the Medicare Payment Advisory Commission (MedPAC) has found that taxpayers continue to spend more per person in Medicare Advantage plans than in traditional Medicare.

Less than a third of people with Medicare are enrolled in Medicare Advantage plans, in part because they restrict people’s access to care and can leave members with costly care needs paying well over $6,000 a year for in-network care plus thousands more if they use out-of-network doctors, which they too often have no choice but to do. But, traditional Medicare requires people have supplemental coverage in order to fill gaps and budget for their care. So, people who believe that they will not need care in the foreseeable future may choose a Medicare Advantage plan to save on the cost of supplemental coverage.

Here’s more from Just Care:



  • I think the only reason nearly one-third of Medicare recipients have Medicare Advantage is because their former employers provide it as the only option to retirees by obtaining a waiver. How can this be stopped? Medicare Advantage was NOT my choice, but I was placed into one without my consent—now I do not think I can go back to Traditional Medicare without consideration of pre-existing conditions. What can be done to end this practice of subverting the recipient’s choice?

      • Perhaps my comment was not as clear as it should have been. I do not think I can go back to Traditional Medicare because I probably cannot afford to buy a Medigap policy now because I have been in a Medicare Advantage plan for over 12 months, and I have pre-existing conditions. Again, I did not choose or consent to being placed in a Medicare Advantage plan. Medigap policies are sold by commercial insurance companies. See pages 83-84 of Medicare and You 2017.

        • Hi, Patricia. I now ask two more questions of you…1) Are there differences state by state re: having an Advantage plan then taking regular Medicare? That does not seem right. Then, Medigap policies like BCBS in my state cost $2000 per year, and that’s a lot. But Medigap policy also covers everything beyond Medicare costs. I also know that Medigap policies must follow Medicare policies exactly. IE, What Medicare covers, Medigap must follow. 2) Does your state not require that? And some of us in my state are eligible for Medicaid or for extra fiscal help.

    • Patrica,your exactly right,same thng happened to me. No choice! But our union can’t bargain for retires,it’s just what they call a gentlemans agreement. After everything is bargained for then it’s us.usually nothing. I worked for the phone company 30 plus years.

  • Virginia, I think you’re missing Patricia’s point. Since her employer put her in a Medicare Advantage Plan (Medicare Part C) when she was first eligible for Medicare she missed her 6 month open enrollment availability for a Medigap policy. She must now submit to medical underwriting that due to her pre-existing conditions may make a Medigap policy either unavailable or unaffordable. I think she should still contact a broker for senior products to see exactly what her options are. Ironically probably the most lenient underwriting for a Medigap policy is with, you guessed it, United Healthcare.

    • Yes, Archer, you are correct. Furthermore, thousands of other Commonwealth of PA retirees were placed, without their knowledge or consent, into Medicare Advantage plans. (Except for our Legislators, of course!) Unforunately, many retirees are stuck as I am because of pre-existing conditions but many just do not even realize how they were harmed by this. We worked for a minimum of 15 years for the privilege of having health benefits (Medicare Supplement and Prescriptions paid by the former employer were promised) in retirement, and this is how we were treated! Thanks, PSSU and SIEU—You took our union dues for years then sold us out! I allege fraud on the part of the former employer in that it hid the fact that we were being placed in Medicare Advantage and what the ramifications of that might be. They just kept telling us how lucky we were!!! Retirees need to be vigilant!

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