UnitedHealth Group Faces DOJ Probes Over Medicare Billing and Coding Practices

UnitedHealth Group, a key player in the U.S. health insurance market providing coverage to over 27 million Americans including nearly five million Texans, is currently under at least two investigations by the U.S. Department of Justice (DOJ). The probes focus on allegations of fraudulent practices involving Medicare billing and the manipulation of diagnosis codes to increase revenue from the federal Medicare program. This acknowledgment marks the first time UnitedHealth Group has publicly confirmed their compliance with DOJ's formal criminal and civil requests.

The investigations into the Medicare billing practices and diagnosis code manipulation suggest that federal regulators are intensifying scrutiny on major health insurers' coding and billing practices, potentially impacting regulatory compliance frameworks and Medicare program integrity. Industry experts highlight that such actions could have widespread implications given the dominance of major insurers like UnitedHealth, Blue Shield, Cigna, and Aetna in the market.

This scrutiny aligns with previous DOJ actions against other large insurers including Aetna, Humana, and Anthem, who faced allegations related to illegal kickbacks tied to Medicare Advantage plans. These high-profile probes emphasize ongoing federal efforts to enforce compliance and fraud prevention in Medicare and related health insurance markets.

UnitedHealth Group's recent financial disclosures indicate a revised revenue forecast for 2025, with expected earnings between $450 billion to $455 billion, reflecting adjustments after a first quarter that did not meet performance expectations. The company's response to the investigations includes initiating third-party reviews of its policies and practices to ensure compliance and mitigate risks.

These developments are occurring amidst a period of significant operational and leadership challenges for UnitedHealth Group, including the loss of its CEO in late 2024. As the investigations proceed, they will be closely monitored by industry stakeholders concerned with regulatory compliance, financial impacts, and the overall integrity of Medicare-related reimbursement processes. These actions also underscore the importance of robust internal controls and transparency within large health insurance organizations to maintain trust and compliance with federal healthcare programs.