Massachusetts Attorney General Andrea Joy Campbell alleges in a new lawsuit that UnitedHealthcare Insurance Company falsely manipulated the health status of MassHealth members enrolled in its Senior Care Options (SCO) plan to secure higher payments from the Commonwealth.

The complaint estimates that the scheme defrauded MassHealth, the state’s Medicaid program, of at least $100 million.   

The AG’s office said MassHealth’s SCO program serves eligible members aged 65 or older living in designated service areas across Massachusetts. Enrollees must receive a comprehensive in-home clinical assessment to determine the member’s health status and assign them one of three levels of care, ranging from least serious and lowest payment rate (Level 1) to most serious and highest payment rate (Level 3). 

United is the largest provider of SCO plans in Massachusetts. 

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Three Strikes

The Attorney General’s Office alleges that United manipulated the health statuses of its members to increase profits in three principal ways.

1-       United allegedly submitted assessments of members in the United SCO Plan that led to their classification as Level 2, which is reserved for members with behavioral health or substance use disorders. United classified members by identifying, in its submissions to MassHealth, that members had diagnoses like depression or anxiety, even though those members lacked any corresponding diagnosis or treatment associated with behavioral health or substantive use disorders.

2-       The AG alleges that United improperly assessed many members in the United SCO Plan with health conditions satisfying Level 3, reserved for members with the most serious health conditions, even though those members did not qualify for Level 3 services. “Beginning in 2018 and continuing into 2019, United became aware through a series of internal reviews that many of its members at Level 3 had been improperly classified. United never disclosed to MassHealth that it had been improperly paid at higher rates for these members prior to their being downgraded, nor has it repaid MassHealth for any of the improperly inflated payments United received while the members were incorrectly classified at Level 3,” the AG said. 

3-       United allegedly submitted assessments to MassHealth for members in the United SCO Plan that represented that those members needed daily skilled nursing services. Despite these representations, most of those members did not need or receive daily skilled nursing services. As a result, United received higher payments from MassHealth for these members than it should have, the AG said. 

UnitedHealthcare responded to the allegations in a statement, calling them “meritless.”

“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,” the insurer said.

Comments or questions? Contact Patrick Connole at pconnole@parkplacelive.com.