DOJ Expands Probe into UnitedHealth’s Medicare Billing Practices

The U.S. Department of Justice is intensifying its investigation into UnitedHealth Group's Medicare billing practices, focusing on the company's use of doctors and nurses to increase government payments through the capturing of lucrative diagnoses. This probe has been ongoing for over a year and has gained momentum as former employees cooperate with federal investigators, highlighting practices that may have inflated Medicare Advantage payments. Key areas under scrutiny include UnitedHealth’s HouseCalls unit, which sends nurses to conduct in-home evaluations of Medicare members using software that prompts the recording of potential diagnoses.

Particular attention is on the use of diagnostic devices like the QuantaFlo, which screens for peripheral artery disease—a diagnosis frequently linked to higher Medicare reimbursement. Investigators are also reviewing UnitedHealth’s internal software, called the "diagnosis cart," which suggests possible conditions based on nurse inputs. Diagnoses such as peripheral artery disease and secondary hyperaldosteronism are central to the inquiry due to their role in generating increased payments.

Data indicates that UnitedHealth’s Medicare Advantage members receive these high-value diagnoses more often than patients in other plans, potentially leading to billions in extra payments. From 2019 to 2021, UnitedHealth averaged an additional $2,735 in payments per nurse home visit—approximately 50% above the industry average—and in 2021 reportedly collected $8.7 billion in payments for diagnoses not matched by treatment claims from doctors or hospitals.

The investigation also considers the role of UnitedHealth-employed physicians who have been found to assign certain high-value diagnoses at unusually high rates. While UnitedHealth asserts that clinical judgment guides diagnosis assignment, the DOJ’s inquiry raises concerns about the impact of software prompts and internal protocols on billing practices. The company has stated that it has not been formally notified about the investigation and maintains confidence in its Medicare Advantage program.

This probe occurs in the broader context of federal efforts to combat healthcare fraud, with recent DOJ actions leading to charges against over 320 individuals involved in fraudulent claims totaling nearly $15 billion. UnitedHealth’s newly appointed CEO, Stephen Hemsley, has acknowledged the situation and promised a thorough review of the practices under question. The outcome of this investigation is likely to influence compliance strategies and regulatory oversight within the Medicare Advantage sector extensively.