Latest news with #EdenPrairie-based
American Military News
17-05-2025
- Business
- American Military News
Adding to UnitedHealth woes, WSJ reports Justice Department has launched criminal investigation
UnitedHealth Group stock was sliding again Thursday as the market took in a report in the Wall Street Journal that the U.S. Department of Justice has launched a criminal fraud investigation of Medicare billing practices, the latest development in a string of allegations about the Eden Prairie-based company. In a story posted late Wednesday, the Journal quoted sources familiar with the matter who said the investigation is overseen by the health care-fraud unit of the Justice Department's criminal division, and has been ongoing since at least last summer. Investigators are focusing on the company's business practices in Medicare Advantage health plans, although the exact nature of the allegations are unclear. The Eden Prairie-based health care said in a statement to the Minnesota Star Tribune Wednesday night that it's not been notified by the Justice Department of any such investigation and called the story 'deeply irresponsible.' 'We stand by the integrity of our Medicare Advantage program,' the health care company said. UnitedHealth Group stock fell 14% in morning trading Thursday, marking the second major downward movement this week after the company abruptly announced Tuesday that CEO Andrew Witty was stepping down, to be immediately replaced as chief executive by Chairman Stephen Hemsley. The news Wednesday followed reports earlier this year that the company's Medicare Advantage business was being investigated in a civil probe, after it had been singled out in a federal watchdog report for the questionable use of diagnosis data to boost payments from the government program for seniors by billions of dollars. Allegations that insurers including UnitedHealthcare, the massive health insurance division at UnitedHealth, have gamed Medicare's risk-rating system in order to wrongly inflate their federal payments are not new. The company is still fighting a whistleblower lawsuit first filed in 2011 by an insider named Benjamin Poehling, who made similar allegations. But investigative news reports over the past year, combined with widespread public anger at the company that was piqued following the killing of a top company executive on a public sidewalk in New York City, have contributed to the sense that UnitedHealth Group — a giant player in the nation's health care economy and the largest firm in Minnesota — has become a company under siege. Hemsley put a brave face on the challenges in an internal message to employees earlier this week, which was obtained by the Minnesota Star Tribune. 'I am optimistic about our future since many of the issues standing in the way of achieving our goals are within our capacity to resolve,' he wrote. 'I know we will approach them with humility, rigor and urgency, guided as always by our mission to help people live healthier lives and help make the health system work better for everyone.' Medicare Advantage is a program in which the government pays private health insurers a per-member, per-month fee to provide medical benefits to seniors. These payments are increased based on 'risk-adjustment' data submitted by insurers, so they are rewarded financially for managing care for people with serious health problems. Historically, insurers faced criticism for shunning patients with high medical costs. In early 2017, the federal government joined a whistleblower lawsuit from a former UnitedHealth Group employee in the Twin Cities who alleged, among other things, that the nation's largest insurer had wrongly received excess Medicare revenue by reviewing medical charts to boost payments without also making data corrections that would have saved the government money. The litigation was initially filed under seal by former employee Poehling in 2011. In March, a court-appointed special master recommended the lawsuit not be allowed to move forward after finding no evidence to support key allegations about the company's alleged gaming risk-adjustment payments. The Justice Department in April said it wanted to push forward with the case, despite the special master's finding of a 'complete failure' of evidence. UnitedHealth Group stood out from its peers in an October 2024 federal watchdog report that questioned how Medicare Advantage insurers used diagnosis data to boost Medicare Advantage payments by billions of dollars. The company was the biggest recipient of the add-on funds based on 'questionable' practices for 2023, according to the report from the Office of the Inspector General (OIG) at the U.S. Department of Health and Human Services. UnitedHealth Group insisted the OIG report was wrong. The watchdog agency published similar findings three years earlier, which UnitedHealth also rejected at the time as misleading and inaccurate. OIG's reporting, plus coverage over the past year from the Wall Street Journal, prompted U.S. Sen. Chuck Grassley, R-Iowa, to demand answers from UnitedHealth Group on billing practices in a letter he sent in February. Last July, the Wall Street Journal published an investigation that alleged UnitedHealthcare and other private insurers in Medicare Advantage made hundreds of thousands of questionable diagnoses that triggered an extra $50 billion in taxpayer-funded payments. UnitedHealth Group pushed back against the newspaper's reporting that summer as well as a series of federal watchdog reports suggesting the company has stood out from others in its use of questionable practices to boost risk-adjustment payments in Medicare Advantage, the privatized version of the government health insurance program for seniors. Then in February 2025, the Journal reported that the DOJ had initiated a separate civil fraud inquiry into UnitedHealth's Medicare billing practices. The company at the time insisted it was not aware of any such investigation. 'We are aware, however, that the Journal has engaged in a yearlong campaign to defend a legacy [Medicare] system that rewards volume over keeping patients healthy and addressing their underlying conditions,' the company said at the time. 'Any suggestion that our practices are fraudulent is outrageous and false.' In addition, UnitedHealth Group is confronting an unprecedented set of challenges. Just this week, the company announced the return of longtime company leader Stephen Hemsley as chief executive, a move meant to restore confidence with investors amid a steep decline in the value of United shares. The stock has plunged with financial missteps under the leadership of former CEO Andrew Witty, who remains as a senior advisor. Meanwhile, the company's reputation was significantly tarnished amid public outrage over health insurance industry practices following the killing of UnitedHealthcare CEO Brian Thompson. Ire has focused on the company due to its status as the nation's largest health insurer plus limited availability of data about claims denials, leaving it open to interpretation. Lawsuits settled just in the past four months alleged the company's health insurance divisions weren't providing sufficient access to an emerging cancer treatment called proton beam radiation therapy as well as emergency room care and urinary drug screenings. Other controversies include the continuing fallout from a massive cyberattack and withering criticism of the pharmacy benefit manager (PBM) industry where UnitedHealth is a major player. The Justice Department sued last year to block the company's proposed acquisition of Amedisys, a home care and hospice company. In February 2024, UnitedHealth Group did not comment when the Wall Street Journal reported the Justice Department had opened an antitrust investigation of the company including interactions between the massive UnitedHealthcare health insurance and medical groups operated by United's Optum division for health care services. And tough investigative reports over the past year or so from the Wall Street Journal and online health care news outlet STAT are among the exhibits cited by shareholders alleging securities fraud by the company in the U.S. District Court of Minnesota. United has pushed back on all fronts. On denials, the company insists it ultimately pays 98% of all claims received that are for eligible members, when submitted in a timely manner with complete, non-duplicate information. For the remainder that are not approved, the majority are instances where the services did not meet the benefit criteria established by the plan sponsor, UnitedHealth says, such as the employer, state or Centers for Medicare & Medicaid Services. In the lawsuits over proton beam therapy and emergency room care, UnitedHealth denied the allegations and said it was reaching settlements to bring litigation to a close while admitting no wrongdoing. On the cyberattack, the company repeatedly has pointed to the billions in financial assistance it's provided to health care providers caught up in system shut down to contain damage from the hack. Pharmacy benefits managers including UnitedHealth's Optum Rx division insist their tactics have been misconstrued and that critics don't appreciate how the companies provide a check on the power of drug companies to set high prices. And UnitedHealth has moved to dismiss the shareholder lawsuit, while contesting Justice Department claims in the Amedisys case. ___ © 2025 The Minnesota Star Tribune. Distributed by Tribune Content Agency, LLC.
Miami Herald
15-05-2025
- Business
- Miami Herald
Adding to UnitedHealth woes, WSJ reports Justice Department has launched criminal investigation
UnitedHealth Group stock was sliding again Thursday as the market took in a report in the Wall Street Journal that the U.S. Department of Justice has launched a criminal fraud investigation of Medicare billing practices, the latest development in a string of allegations about the Eden Prairie-based company. In a story posted late Wednesday, the Journal quoted sources familiar with the matter who said the investigation is overseen by the health care-fraud unit of the Justice Department's criminal division, and has been ongoing since at least last summer. Investigators are focusing on the company's business practices in Medicare Advantage health plans, although the exact nature of the allegations are unclear. The Eden Prairie-based health care said in a statement to the Minnesota Star Tribune Wednesday night that it's not been notified by the Justice Department of any such investigation and called the story "deeply irresponsible." "We stand by the integrity of our Medicare Advantage program," the health care company said. UnitedHealth Group stock fell 14% in morning trading Thursday, marking the second major downward movement this week after the company abruptly announced Tuesday that CEO Andrew Witty was stepping down, to be immediately replaced as chief executive by Chairman Stephen Hemsley. The news Wednesday followed reports earlier this year that the company's Medicare Advantage business was being investigated in a civil probe, after it had been singled out in a federal watchdog report for the questionable use of diagnosis data to boost payments from the government program for seniors by billions of dollars. Allegations that insurers including UnitedHealthcare, the massive health insurance division at UnitedHealth, have gamed Medicare's risk-rating system in order to wrongly inflate their federal payments are not new. The company is still fighting a whistleblower lawsuit first filed in 2011 by an insider named Benjamin Poehling, who made similar allegations. But investigative news reports over the past year, combined with widespread public anger at the company that was piqued following the killing of a top company executive on a public sidewalk in New York City, have contributed to the sense that UnitedHealth Group - a giant player in the nation's health care economy and the largest firm in Minnesota - has become a company under siege. Hemsley put a brave face on the challenges in an internal message to employees earlier this week, which was obtained by the Minnesota Star Tribune. "I am optimistic about our future since many of the issues standing in the way of achieving our goals are within our capacity to resolve," he wrote. "I know we will approach them with humility, rigor and urgency, guided as always by our mission to help people live healthier lives and help make the health system work better for everyone." Medicare Advantage is a program in which the government pays private health insurers a per-member, per-month fee to provide medical benefits to seniors. These payments are increased based on "risk-adjustment" data submitted by insurers, so they are rewarded financially for managing care for people with serious health problems. Historically, insurers faced criticism for shunning patients with high medical costs. In early 2017, the federal government joined a whistleblower lawsuit from a former UnitedHealth Group employee in the Twin Cities who alleged, among other things, that the nation's largest insurer had wrongly received excess Medicare revenue by reviewing medical charts to boost payments without also making data corrections that would have saved the government money. The litigation was initially filed under seal by former employee Poehling in 2011. In March, a court-appointed special master recommended the lawsuit not be allowed to move forward after finding no evidence to support key allegations about the company's alleged gaming risk-adjustment payments. The Justice Department in April said it wanted to push forward with the case, despite the special master's finding of a "complete failure" of evidence. UnitedHealth Group stood out from its peers in an October 2024 federal watchdog report that questioned how Medicare Advantage insurers used diagnosis data to boost Medicare Advantage payments by billions of dollars. The company was the biggest recipient of the add-on funds based on "questionable" practices for 2023, according to the report from the Office of the Inspector General (OIG) at the U.S. Department of Health and Human Services. UnitedHealth Group insisted the OIG report was wrong. The watchdog agency published similar findings three years earlier, which UnitedHealth also rejected at the time as misleading and inaccurate. OIG's reporting, plus coverage over the past year from the Wall Street Journal, prompted U.S. Sen. Chuck Grassley, R-Iowa, to demand answers from UnitedHealth Group on billing practices in a letter he sent in February. Last July, the Wall Street Journal published an investigation that alleged UnitedHealthcare and other private insurers in Medicare Advantage made hundreds of thousands of questionable diagnoses that triggered an extra $50 billion in taxpayer-funded payments. UnitedHealth Group pushed back against the newspaper's reporting that summer as well as a series of federal watchdog reports suggesting the company has stood out from others in its use of questionable practices to boost risk-adjustment payments in Medicare Advantage, the privatized version of the government health insurance program for seniors. Then in February 2025, the Journal reported that the DOJ had initiated a separate civil fraud inquiry into UnitedHealth's Medicare billing practices. The company at the time insisted it was not aware of any such investigation. "We are aware, however, that the Journal has engaged in a yearlong campaign to defend a legacy [Medicare] system that rewards volume over keeping patients healthy and addressing their underlying conditions," the company said at the time. "Any suggestion that our practices are fraudulent is outrageous and false." In addition, UnitedHealth Group is confronting an unprecedented set of challenges. Just this week, the company announced the return of longtime company leader Stephen Hemsley as chief executive, a move meant to restore confidence with investors amid a steep decline in the value of United shares. The stock has plunged with financial missteps under the leadership of former CEO Andrew Witty, who remains as a senior advisor. Meanwhile, the company's reputation was significantly tarnished amid public outrage over health insurance industry practices following the killing of UnitedHealthcare CEO Brian Thompson. Ire has focused on the company due to its status as the nation's largest health insurer plus limited availability of data about claims denials, leaving it open to interpretation. Lawsuits settled just in the past four months alleged the company's health insurance divisions weren't providing sufficient access to an emerging cancer treatment called proton beam radiation therapy as well as emergency room care and urinary drug screenings. Other controversies include the continuing fallout from a massive cyberattack and withering criticism of the pharmacy benefit manager (PBM) industry where UnitedHealth is a major player. The Justice Department sued last year to block the company's proposed acquisition of Amedisys, a home care and hospice company. In February 2024, UnitedHealth Group did not comment when the Wall Street Journal reported the Justice Department had opened an antitrust investigation of the company including interactions between the massive UnitedHealthcare health insurance and medical groups operated by United's Optum division for health care services. And tough investigative reports over the past year or so from the Wall Street Journal and online health care news outlet STAT are among the exhibits cited by shareholders alleging securities fraud by the company in the U.S. District Court of Minnesota. United has pushed back on all fronts. On denials, the company insists it ultimately pays 98% of all claims received that are for eligible members, when submitted in a timely manner with complete, non-duplicate information. For the remainder that are not approved, the majority are instances where the services did not meet the benefit criteria established by the plan sponsor, UnitedHealth says, such as the employer, state or Centers for Medicare & Medicaid Services. In the lawsuits over proton beam therapy and emergency room care, UnitedHealth denied the allegations and said it was reaching settlements to bring litigation to a close while admitting no wrongdoing. On the cyberattack, the company repeatedly has pointed to the billions in financial assistance it's provided to health care providers caught up in system shut down to contain damage from the hack. Pharmacy benefits managers including UnitedHealth's Optum Rx division insist their tactics have been misconstrued and that critics don't appreciate how the companies provide a check on the power of drug companies to set high prices. And UnitedHealth has moved to dismiss the shareholder lawsuit, while contesting Justice Department claims in the Amedisys case. Copyright (C) 2025, Tribune Content Agency, LLC. Portions copyrighted by the respective providers.
Yahoo
20-04-2025
- Business
- Yahoo
Proposed $600K equipment upgrade aims to improve live video of Rochester council meetings
Apr. 20—ROCHESTER — A $592,000 upgrade to audio-visual equipment in the shared Rochester and Olmsted County chambers of the city-county Government Center will be reviewed Monday. The Rochester City Council will be asked to approve funding $346,000 of the cost, using the majority of the $390,000 the city has collected through quarterly cable franchise fees from Charter Communications, which provides service through the Spectrum brand. The county would also pay for about less than half the cost. The dedicated public, education and government funds can only be used for specific expenses, which include the cost of technology needed to share videos of government meetings "We have a pretty limited universe of alternatives that we can spend that money on," Deputy City Administrator Aaron Parrish told the council in March as the council discussed seeking proposals for the upgrades. Originally estimated at $600,000, Parrish said the last time the chamber's audio-visual system was completely upgraded was in 2014. "Most of it is beyond useful life and the period of time where we can service it," he said. The work proposed in a bid by Eden Prairie-based AVI Systems calls for $328,000 in equipment costs and nearly $210,000 for engineering and other services related to installation, with an added $54,000 to cover shipping equipment from various vendors and system support. Jeremiah Baumann, the Rochester Public Library's communications and engagement manager, said some existing equipment in the chamber will be repurposed, so recent upgrades are expected to be integrated into the project. "Most of our cable equipment is more than likely going to be reused, because it's newer, because it did all die before," he said, pointing to ongoing challenges to provide a live video of meetings to the local cable provider. Baumann said some of the past struggles have been tied to the inability to ensure equipment is compatible in a system that has mixed analog and digital components over the years. It's resulted in needing to reset the existing system weekly and concerns that some connections could fail. "This is a chance to unify a lot of equipment, so it's the most compatible," he said. In addition to improving the livefeed and streaming quality of meetings, the upgrade is expected to enhance options for remote participation in meetings, improve captioning of meeting video, upgrade hearing — assistance options in the chamber and support future integration of meetings held in other locations. While the full $592,000 upgrade is expected to be proposed Monday, the council requested options be presented to scale back the project once a final bid was received. "I'd like to see it done with what we have to have, not what we want," council member Shaun Palmer said of the upgrades, pointing to a desire to review potential project cuts to reduce costs. City staff identified roughly $59,000 in potential project cuts. They include: * Replacing a planned LED display with a projector for viewing in chambers to save $5,700. * Starting with a one-year subscription for captioning services to cut the $50,000 initial cost in half but potentially adding $200,000 to expenses over 10 years. * Opting for a wireless hearing-assisted system, rather than an integrated system, to save up to $21,000. * Cutting a planned $9,600 ADA-accessible lectern from the project. Parrish said the entire project is proposed to increase accessibility to council and county board meetings into the future, with technology that will be able to meet future demands. While the local government bodies are not required to provide livestreams or cable access to the meetings, he said they have decided to fund the service to meet the expectations of residents. "We're trying to get us to a great spot, where we can deliver a high value and do good production with council meetings," he said. While the county is expected to pay for less than half of the project — $246,000 — Parrish said it plans to spend an additional $50,000 to update lighting, carpet and drapes in the chambers while the new equipment is installed. Parrish said the project installation is expected to take two months, which will require moving meeting locations. No specific date for the work has been provided. Meetings scheduled to be held during the week of April 21 include: Rochester —City Council, 6 p.m. Monday in council chambers of the city-county Government Center, 151 Fourth St. SE. The meeting will livestream at and be available on Spectrum cable channel 180 or 188. —Heritage Preservation Commission, 5 p.m. Tuesday in council chambers of the city-county Government Center. —Planning and Zoning Commission, 5 p.m. Wednesday in council chambers of the Government Center. —Citizens Advisory on Transit, 4:30 p.m. Thursday in room 104 of City Hall, 201 Fourth St. SE. Olmsted County —Rochester-Olmsted Council of Governments, noon Wednesday in conference room 186, 2122 Campus Drive SE. —Soil and Water Conservation District Board, 8 a.m. Thursday in conference room 109 at 1188 50th St. SE Rochester Rochester Public Schools —School Board, 5:30 p.m. Tuesday in the boardroom of the Edison Building, 615 Seventh St. SW.
Yahoo
15-04-2025
- Business
- Yahoo
St. Paul Midway Cub adds more than 100 shopping carts after dry spell
In St. Paul's Midway, the long, nearly cart-less winter of every Cub customer's discontent is finally over. After weeks, if not months, of complaints about what appeared to be a near-complete lack of supermarket carts, the Cub at 1440 University Ave. W. recently rolled out dozens of the highly-in-demand wheeled wonders, which had dwindled down to little short of collector's items. During the dry spell, the few customers who had scored carts would be approached by customers who had not as they bagged their groceries, leading to an awkward exchange near the cash register that looked a bit like panhandling. Similar acts of desperation between the cart-wielding haves and cart-less have-nots unfolded in the supermarket lobby and parking lot. 'When I went shopping … I still couldn't find a cart, and on the way out of the store an employee followed me to my car,' wrote a customer on Facebook on March 21. 'That was kind of creepy. He wanted my cart, obviously.' As winter wore on, customers approached store management for explanations and tried to find their way up the chain of command from there. Based in Providence, R.I., United Natural Foods, Inc. acquired Eden Prairie-based SuperValu, Inc., parent company to Cub, in 2018. On Feb. 14, a customer shared on Facebook a response from a store manager indicating that a concerned community member dropped off dozens of carts, and that Cub was looking to its sister store in Stillwater for more. Still, the shortage continued. The lean times fueled social media speculation that Cub did not intend to renew its lease in the Midway, a rumor that resurfaces online every few months, driven in part by Cub's decisions in recent years to close its self check-out lanes and burrito bar and place cold medicine and other pharmacy items behind locked glass. Store managers and employees repeatedly denied that's the case. Other rumors had it that the carts could be found at a nearby homeless encampment, or strewn about the Midway. 'I don't typically delve into conspiracy theories, but I find myself fully immersed in this one,' wrote Don Allen on his blog, on April 2. 'The Cub Foods on University Avenue in St. Paul, Minnesota, situated in the vibrant heart of Midway, has been eerily devoid of shopping carts for over a month now. How can you shop on a Sunday after church and not have a cart — and only two cashier lanes open?' Another Facebook user wrote on March 30: 'Just went to Midway Cub Foods around 11:30 this morning. No carts in the entry. No carts in the parking lot. Self checkout no longer being used. One checkout line open! Felt like a store on the verge of closure! Anyone hear or know if this location is closing?' Wrote yet another Facebook user on April 1: 'None of this would fly in neighborhoods with different demographics.' Promising signs of grocery life have finally blossomed with the first buds of spring. In the past week, the Midway Cub has added more than 100 carts to replenish its stash, which a spokesperson said were pruned by cart scofflaws. 'At our location on University Avenue in St. Paul, we have encountered some issues with community members removing carts from our parking lot and not returning them,' said Kristen Jimenez, a spokesperson for United Natural Foods, Inc., or UNFI, in an email last Friday. 'To address this, we recently added 100+ new shopping carts to this store's inventory and are also working with the mayor's office and our local police department to find ways to reduce theft of shopping carts as much as possible.' Jurors convict man, 54, in fatal shootout that followed St. Paul funeral reception St. Paul man convicted of fentanyl conspiracy Volunteer at Roseville church charged with sex assault of 4 young children For the country's 250th anniversary, American Cruise Lines plan nationwide river cruises that include St. Paul stops What's driving down gun violence in St. Paul? Solving nonfatal shootings and outreach are helping, officials say
Miami Herald
26-03-2025
- Business
- Miami Herald
Lawsuit alleges securities fraud, profit-boosting scheme at UnitedHealth Group
A massive pension plan in California alleges UnitedHealth Group has engaged in a wrongful profit-making scheme through its Medicare Advantage business that wasn't disclosed, allowing top executives to reap millions in stock trades based on nonpublic information, according to an amended lawsuit filed in Minnesota this month. The Eden Prairie-based health care giant blasted the complaint, saying in a legal filing that it substitutes page volume for substance, ignores government support for the company's Medicare Advantage practices and misreads records showing executives actually increased their stock holdings, "which is the opposite of selling to profit from alleged fraud." The 158-page complaint in the U.S. District Court of Minnesota, filed last year and amended late last week, incorporates allegations of questionable Medicare Advantage billing practices at UnitedHealth Group that were detailed in separate investigative reporting projects last year by the Wall Street Journal and the online publication STAT. CalPERS, the pension fund that manages $500 billion in assets for public sector retirees in California, is lead plaintiff in the putative class-action complaint, which was brought on behalf of purchasers of UnitedHealth Group common stock between Sept. 22, 2021 and Feb. 20, 2025. "As the nation's largest public pension fund, CalPERS purchased more than 1.8 million shares of UnitedHealth stock during (a two-year portion of) the period covered by the lawsuit," the California Public Employees' Retirement System said in a statement to the Minnesota Star Tribune. "Our court filings ... state that the pension fund posted losses of more than $76.3 million in the investment (between March 14, 2022, and Feb. 27, 2024) due to the alleged actions of UnitedHealth - larger losses than any other plaintiff." UnitedHealth Group is parent company for UnitedHealthcare, the nation's largest health insurer, and Optum, a fast-growing health services business that provides IT consulting, pharmacy benefits and a national network of outpatient medical clinics. The clinics, and their interaction with the company's Medicare Advantage health plans, have been a focus of the recent investigative journalism reports as well as the CalPERS lawsuit. UnitedHealth Group insists the complaint fails to show any false or misleading statements, doesn't specify what laws the company allegedly violated and contradicts the fact that the federal agency running Medicare "has consistently found that programs like the one the plaintiff complains about are legal, provide significant benefits for the health care system and are heavily scrutinized to deter abuse." CalPERS sued UnitedHealth Group nearly 20 years ago when the company was rocked by allegations that Dr. William McGuire, the CEO at the time, wrongly realized enormous personal wealth via "backdated" stock options. The new lawsuit names the company as a defendant along with Brian Thompson, the UnitedHealth Group executive who was killed on a New York City sidewalk in December while walking to a company investor conference. Chief executive Andrew Witty also is a defendant in the CalPERS litigation, along with Stephen Hemsley, the UnitedHealth Group board chair who served as chief executive for more than a decade after McGuire stepped down. Executives made millions in stock trades while making or causing to be made false or misleading statements that pushed up the value of the company's stock, according to the lawsuit. In particular, they sold more than $100 million in stock, the complaint alleges, after learning of a nonpublic investigation by the U.S. Department of Justice that was later reported by the Wall Street Journal. The amended lawsuit alleges securities fraud and reads like an unauthorized biography of the giant health care corporation, describing the Minnesota origins of UnitedHealth Group in the 1970s and allegations the company has grown by gaming landmark federal laws passed in 1997 and 2010. The earlier statute launched a program known as Medicare Part C, in which health insurers sell Medicare Advantage health plans offering a privatized version of government health insurance benefits for seniors. The lawsuit outlines a series of accusations related to UnitedHealthcare's huge growth within Medicare Advantage and a scheme to allegedly game a system via "upcoding," where insurers get paid more for covering patients suffering more health problems. "UnitedHealth induced providers to find new diagnoses by paying bonuses to providers who upcoded," the lawsuit states. "UnitedHealth trained providers to use 'buddy codes,' that is adding multiple new diagnoses based upon existing ones. UnitedHealth also purposefully leveraged its HouseCalls program, whereby the Company would dispatch nurse practitioners to members' homes to perform physical assessments in search of new diagnoses, even if they were not medically supported." The lawsuit includes accounts from seven confidential witnesses, including a primary care physician dubbed "CW3,″ who described corporate pressure to change how physicians treated Medicare Advantage (MA) patients after Optum in late 2018 became majority shareholder in the doctor's clinic. "The clinic became hyper focused on converting non-MA members to being members of UnitedHealth's MA program, which was communicated through weekly emails, meetings, and outreach from clinic's managed care department," the lawsuit alleged. "Due to pressure from management, (the doctor and staff) began prioritizing CW3's UnitedHealth MA members over CW3's other patients. CW3 also described a widespread campaign at the clinic to maximize the (diagnosis) codes for each of the clinic's UnitedHealth members in order to increase risk-adjustment scores." The lawsuit alleges UnitedHealth Group has gamed rules under the federal Affordable Care Act of 2010 that regulates the "medical loss ratio" (MLR) of health insurers. These rules force health plans to spend between 80% and 85% of member premiums on health care for patients, rather than administrative costs and insurer profits. The lawsuit alleges UnitedHealth Group bypassed MLR restrictions by having its health insurance division pay for services provided at Optum clinics and cites a STAT report that said rates were higher than clinics received from another national insurer. "UnitedHealthcare could collect premiums, send patients to Optum Health for treatment, and pay itself (through Optum) for the requisite level of healthcare needed to satisfy the MLR requirements," the lawsuit states. "Designing its corporate structure in this way allowed UnitedHealth to circumvent the ACA's MLR restrictions and retain greater profits on both the insurance side and the provider side of the ledger." CalPERS also alleges UnitedHealth misled investors about data firewalls within its Change Healthcare subsidiary, which Optum acquired for about $13 billion in 2022. UnitedHealth disclosed in February 2024 that Change Healthcare had been breached in the largest known health care computer-hacking incident in years, affecting 190 million people. UnitedHealth has stressed that a court hearing in a Justice Department challenge to the acquisition found UnitedHealth Group had policies and incentives to protect information, including with respect to internal firewalls. A motion from UnitedHealth in February to dismiss the original complaint did not address the allegations on medical loss ratios, but argued plaintiffs had failed to define the alleged upcoding in Medicare Advantage while noting Medicare allows companies to use health risk assessments, chart reviews and other measures to find additional diagnoses. The federal government performs audits "that measure the accuracy of risk-adjusted diagnoses, including those identified through House Calls visits," the company said. And on executive stock trades, UnitedHealth Group argued that defendants increased their overall holdings, calling this "the last thing they would do" if the goal had been to dump stock to avoid losses. Plus, sales were submitted for preclearance by the company's legal team, "hardly the action of fraudsters trying to profit from improper insider trades." UnitedHealth Group has until May 20 to file a motion to dismiss the amended complaint. _____ Copyright (C) 2025, Tribune Content Agency, LLC. Portions copyrighted by the respective providers.
