Two whistleblowers have accused United Healthcare Services Inc. of intentionally mishandling or concealing hundreds of complaints in order to jack up its quality ratings and get bonus payments it didn't deserve. United Healthcare Services runs the country's largest Medicare Advantage plan, and Medicare paid some $1.4 billion in quality bonuses last year -- compared to only $564 million in 2015.
The whistleblowers' allegations were revealed in a False Claims Act lawsuit recently unsealed in Wisconsin. The whistleblowers were identified as a sales agent and a sales manager with the company. The company rejects the allegations.
According to the lawsuit, United Healthcare received hundreds of fraud and misconduct complaints but never revealed them to federal officials. Moreover, the suit alleges that the company actively steered customers to file their complaints internally rather than with federal authorities. The Centers for Medicare & Medicaid Services, or CMS, relies on health insurers to report problems and doesn't try to verify their accuracy before issuing quality bonuses, according to Kaiser Health News.
For example, the suit says that in March 2016 United Healthcare received 771 serious complaints that should have been sent to CMS, but only 257 were actually forwarded.
In addition, the suit alleges that United Healthcare failed to properly investigate many claims or discounted evidence in order to close more complaints and unfairly raise its quality score. In fact, about 84 percent of major complaints were improperly investigated and then documented as "inconclusive" or "unsubstantiated."
These included instances in which at least one United Healthcare sales agent forged customers' signatures on enrollment forms. A "brazen kickback scheme" by another agent was investigated and marked "unsubstantiated" even though that agent was fired.
United Healthcare is under increasing scrutiny from regulators, along with several other False Claims Act suits. The FCA allows private citizens to file lawsuits on behalf of the federal government when they notice fraud in federal programs. When the case is successful, the citizen is rewarded with a share of the money recovered.