The U.S. Justice Department has launched a civil fraud investigation into UnitedHealth Group’s Medicare billing practices, according to a recent report by The Wall Street Journal. The inquiry centers on how the company records patient diagnoses in a way that increases government payments for its Medicare Advantage plans.
UnitedHealth has denied any wrongdoing, dismissing the allegations as “outrageous and false.” However, scrutiny over the practices of the nation’s largest health insurer adds to growing concerns about potential systemic abuses within the Medicare Advantage program, which serves more than 30 million Americans.
The investigation focuses on risk-adjustment practices, a system designed to ensure Medicare Advantage plans receive appropriate funding based on the health conditions of their enrollees. Critics argue that insurers have manipulated this system by inflating patient diagnoses to secure higher reimbursements from the federal government.
This is not the first time UnitedHealth Group has faced legal challenges regarding its Medicare billing. The company has been the subject of multiple lawsuits and audits related to risk adjustment, with previous cases resulting in settlements and regulatory penalties. However, this new Justice Department probe signals heightened federal oversight and a potential crackdown on fraudulent billing practices in the Medicare Advantage market.
Health policy experts note that Medicare Advantage fraud is a broader issue that extends beyond UnitedHealth. Investigations into similar practices have implicated several major insurers, raising questions about the structural incentives within the program that may encourage overbilling.
Sarah M. Worthy, CEO of healthcare technology company DoorSpace, was even more direct in her criticism of UnitedHealth’s business practices.
“When we look at the lawsuits against UnitedHealth, UHC is denying claims to patients who see their preferred non-UHC providers while inflating claims to their own providers, effectively ‘double dipping,’” Worthy said. “American tax dollars are supporting the purchase of health executives’ vacation homes and yachts instead of the healthcare for Americans it’s intended for. Americans need to get angry and demand policies to rein in the profiteering in the US health insurance industry.”
Critics argue that this alleged “double dipping” practice—denying claims while simultaneously maximizing government reimbursements—harms both patients and taxpayers. Medicare Advantage enrollees often face unexpected denials for necessary care, forcing them to either pay out-of-pocket or forgo treatment. Meanwhile, the federal government is paying billions in potentially inflated claims, straining public healthcare funding.
The Justice Department’s probe into UnitedHealth could have significant consequences for the broader insurance industry. If regulators uncover widespread fraud, it may lead to substantial financial penalties, policy reforms, or even structural changes to the Medicare Advantage program.
Congress has also taken an interest in curbing potential abuse in the program. Lawmakers from both parties have called for increased oversight of Medicare Advantage plans, particularly as enrollment continues to grow. The Centers for Medicare & Medicaid Services (CMS) has proposed new rules aimed at improving billing transparency and reducing fraud, but enforcement remains a challenge.
As the investigation unfolds, healthcare advocates and policymakers will be watching closely. The outcome of the probe could set a precedent for how aggressively the federal government will pursue fraud in the Medicare Advantage industry and whether systemic reforms will be implemented to protect patients and taxpayers from exploitative billing practices.
About DoorSpace
Based in Houston, Texas, DoorSpace is delivering cutting-edge talent development software through their innovative, cloud-based platform. With a people-centric approach that helps healthcare professionals focus on what matters most – their patients and themselves – DoorSpace is changing the game. By seamlessly integrating personnel, administration monitoring, and organization systems, they’re streamlining healthcare processes and helping organizations retain and develop clinical talent. DoorSpace is all about making work better for the people who make a real difference.
