DOJ Investigates UnitedHealth Group Over Medicare Advantage Billing Practices
The U.S. Department of Justice has been investigating UnitedHealth Group's Medicare Advantage billing practices since 2024, focusing on allegations of upcoding – a practice where patient diagnoses are exaggerated to increase federal reimbursements. Former UnitedHealth physicians have been interviewed by DOJ prosecutors along with the FBI and HHS Office of Inspector General to understand coding and diagnosis approaches used in Medicare Advantage claims. This probe is part of a broader regulatory crackdown; CMS has announced plans to audit all Medicare Advantage plans annually to identify potential improper billing.
UnitedHealth Group reportedly received $8.7 billion in 2021 for diagnoses that were not documented in treatment claims, highlighting the scale of alleged discrepancies. The company, however, maintains that its Medicare Advantage coding practices are among the most accurate in the industry and has criticized media coverage as relying on incomplete and misleading data. A longstanding legal challenge to UnitedHealth’s Medicare Advantage practices was recently recommended for dismissal by a special master, citing lack of evidence for wrongdoing.
The investigation reflects increasing regulatory scrutiny across the Medicare Advantage market as CMS seeks to ensure compliance and prevent fraud in federal healthcare spending. Upcoding allegations have impacted nearly every major payer, prompting intensified audits and enforcement actions. Legal outcomes and ongoing investigations bear close watching by market participants given the financial stakes and regulatory implications.
UnitedHealth’s statement emphasized their commitment to program integrity and disputed claims of improper payments. Meanwhile, DOJ investigations continue to assess whether criminal charges related to Medicare Advantage fraud are warranted. This case fits within a broader governmental effort to tighten control over Medicare Advantage expenditures, affecting payer reimbursement models, compliance programs, and audit readiness across the industry.
Insurance professionals should monitor developments as Medicare Advantage coding compliance remains a critical focus area for payers and providers. Providers may experience increased scrutiny in diagnosis documentation, while payers need robust controls to mitigate risk of improper billing. The trend toward tighter CMS audits indicates heightened prioritization of fraud detection and prevention in Medicare Advantage programs moving forward.