Federal Medicare Billing Probe into UnitedHealth May Redefine Lab Diagnostics Oversight

The ongoing federal investigations into UnitedHealth Group's Medicare Advantage billing practices are attracting attention across the healthcare and insurance sectors. The investigations focus on allegations that UnitedHealth inflated patient diagnoses to receive higher Medicare payments. UnitedHealth is cooperating with both criminal and civil inquiries led by the Department of Justice (DOJ), following reports of the probes earlier this year.

The company's cooperation includes responding to information requests and commissioning a third-party review of its business practices, expected to conclude by the end of the third quarter. The DOJ's criminal investigation involves interviews with doctors about potential pressure to submit claims for diagnoses that increase Medicare Advantage payments, while a civil inquiry has scrutinized the use of retrospective chart reviews and in-home assessments to raise patient risk scores. Clinical laboratories are likely to experience increased regulatory scrutiny as they provide diagnostic data that supports coded conditions used in reimbursement. There may be heightened requirements around documentation, test utilization, data integrity, and coding accuracy.

UnitedHealth defends its practices citing CMS audits that rank its practices as highly accurate and referencing a court recommendation questioning the sufficiency of DOJ's evidence in related legal actions. The Medicare Advantage segment is the largest revenue source for UnitedHealth, with $139 billion in revenue last year, but rising medical costs and regulatory pressures have led to suspended financial forecasts. This situation is drawing increased federal regulatory focus on Medicare Advantage billing and the role of diagnostic data, with implications for payers, providers, and clinical labs involved in the diagnostics and billing ecosystem.