The state of Massachusetts has filed a lawsuit against UnitedHealthcare (NYSE: UNH), alleging $100 million in fraudulent Medicaid billing practices, including misclassifying patients as having behavioral health or substance use disorders without a valid diagnosis.
Specifically, the suit alleges that UnitedHealthcare was paid on a per-member-per-month basis for caring for dual-eligible enrollees in the state’s Mass Health Senior Care Organization (SCO), based on the health plan’s assessment of their members’ health conditions. The plan received higher payments for members with more serious health conditions.
The suit claims the health plan classified members at a level reserved for members with behavioral health or substance use disorders, despite members lacking a corresponding diagnosis or treatments associated with the condition. The state claims that this resulted in United receiving higher capitation payments than it should have.
Additionally, the suit also alleges that the health plan classified individuals as having serious health conditions without meeting the proper criteria. According to the filing, individuals classified as having a serious health condition needed skilled nursing services either daily or three times a week, but the suit claims the majority of patients in this category did not receive any of these services.
UnitedHealthcare denies the claims.
“The Massachusetts Attorney General’s complaint is meritless and doesn’t accurately describe our Senior Care Options program, which helps seniors with complex care meet their individual health needs,” a UnitedHealthcare spokesperson told Behavioral Health Business in an email statement. “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.”
The state is seeking to recover the $100 million it claims it overpaid and notes that, under the Massachusetts False Claims Act, that amount could be tripled, leaving the health insurance plan on the hook for $300 million if found liable.