Summary Judgment Recommended in UnitedHealth Medicare Reimbursement Case

A crucial development in U.S. health insurance litigation involves UnitedHealth Group in a False Claims Act (FCA) case, where a court-appointed special master recommended summary judgment for UnitedHealth.

The allegations claimed UnitedHealth was improperly reimbursed by Medicare Advantage based on conflicting diagnostic codes between provider submissions and internal reviews, potentially involving a misappropriation of about $2.1 billion. However, the special master, retired U.S. magistrate judge Suzanne Segal, argued that discrepancies alone couldn’t demonstrate that the provider-submitted codes were incorrect without concrete evidence.

The case focused heavily on the materiality of discrepancies, with the special master reinforcing that materiality is crucial under the FCA, aligning with the Supreme Court's interpretation of the law as primarily anti-fraud. As of April 2025, the government has objected to the Special Master's report, indicating a continuation of the legal discourse. This decision and ongoing lawsuit illustrate the complex interplay between regulatory compliance, provider billing integrity, and payer obligations within the U.S. Medicare Advantage program.