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DOJ Sues UnitedHealth, Alleges $1B Medicare Fraud


The Department of Justice filed its second lawsuit this month against UnitedHealth, alleging inflated risk adjustment payments.

Welcome to Practice Rounds, our weekly column exploring what's being covered in the larger world of healthcare.

Feds Sue UnitedHealth Group

On Tuesday, the U.S. Justice Department (DOJ) intervened in a lawsuit against UnitedHealth, accusing the company of procuring in access of $1 billion from Medicare of which it had no right. This marks the second time this month the DOJ has sued the nation's largest health insurer regarding inflated payments.

The lawsuit, originally brought by former company executive Benjamin Poehling, alleges UnitedHealth obtained inflated risk adjustment payments based on untruthful and inaccurate information about the health status of patients enrolled in its Medicare Advantage plans.

UnitedHealth has more than 50 Medicare Advantage and Drug Prescription plans providing healthcare services and prescription drug benefits to millions of Medicare beneficiaries nationwide. The company receives a monthly risk adjustment payment from Medicare for each enrolled beneficiary. The risk adjustment payments are based on the health status of the beneficiary.

In a press release, Acting Assistant Attorney General Chad A. Readler of the Justice Department's Civil Division said his agency's "pursuit of this matter illustrates its firm commitment to ensure the integrity of the Medicare Program, including those parts of the program that rely on the services of Medicare Advantage Organizations."

Poehling originally filed his lawsuit in 2011 under the False Claims Act, allowing whistleblowers to sue companies on the government's behalf to recover taxpayer money paid out based on fraudulent claims.

Medical Groups against Medicare Budget Panel

Over 650 medical organizations have signed a letter to Congress supporting the elimination of the Independent Payment Advisory Board (IPAB).

The IPAB, a 15 member board, was originally created as part of the Affordable Care Act (ACA) to help reduce Medicare costs through recommendations aimed at achieving savings. If Medicare funding exceeds set limits, the IPAB was to pass immediate reforms, which would be scored in a one-year window.

But, the IPAB seats were never filled, due to the unlikelihood of approval from House Republicans. Although the seats remain empty, this vacancy does not erase the board's original charge. If Medicare spending levels trigger IPAB action, and no members exist, the HHS secretary would be required to submit "fast-track" recommendations.

"As constructed, IPAB is granted unprecedented powers – even the ability to change laws previously enacted by Congress – with virtually no oversight," the organizations state in the letter.

The united organizations also voiced concern that Medicare reimbursement cuts would further reduce access for patients and diminish revenues for providers. This cost would be passed on to employers and consumers, according to the letter.

"We strongly support bringing greater cost-efficiency to the Medicare program. We also advocate continuing efforts to improve the quality of care delivered to Medicare beneficiaries," the letter says. 

Treatment by Older Doctors Tied to Higher Mortality

Hospitalized patients 65 and older could face a slightly higher risk of dying within a month of their admittance when treated by an older physician, according to a new study published Tuesday by The BMJ.

The study, conducted by a group of Harvard professors, included 736,537 hospital inpatients who were receiving Medicare, and were treated between 2011 and 2014. The 18,854 Doctors involved in the study were assigned patients based on work schedules and case specifics.

The researchers found that the 30-day mortality rate was 10.8 percent for older people treated by doctors under 40 years of age. When a doctor was between 40 and 49 years old, the patient mortality rate was 11.1 percent. For physicians from 50 to 59 years old, the patients’ 30-day mortality rate was 11.3 percent. Seniors cared for by doctors aged 60 and up faced the highest 30-day mortality rate at 12.1 percent.

"Patients in the hospital treated by older hospitalists have higher mortality [rates] than patients cared for by younger hospitalists, except for hospitalist physicians with high volumes of patients. We found similar associations among patients treated by general internists. Readmission rates and costs of care did not meaningfully vary with physician age," the study concludes.

Quote of the Week

"Young [PA] graduates, both male and female, often select disciplines that are very demanding, requiring 12-14-hour days. As their lifestyle changes and they settle down and have families…they have the freedom to move across disciplines to those that are more conducive to a [good] work-life balance." - Dawn Morton-Rias, PA-C on the rise of PAs nationwide

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