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Massachusetts investigating insurer for possible Medicare overcharging

The state Attorney General's office is looking at whether United Healthcare, which offers senior care option plans to Medicare-eligible Massachusetts seniors, has been billing the state for a level of care some of its subscribers don't need.

Disclosure of the investigation comes in a suit filed today in Suffolk Superior Court, in which the Attorney General's office is asking a judge to order the insurer to hand over documentation the office says it needs for its probe under the Massachusetts False Claims Act.

The company is also under investigation for possible anti-trust issues by federal regulators.

According to the state's complaint, at issue is how much of a set monthly fee the state pays the insurer for a certain level of basic care, depending on which of three levels a patient is placed at: Able to live completely independently, needs some help with daily tasks or needs so much help they might be better off in a nursing home. The state pays a higher amount per patient in the last category than the second, and more per patient in the second than in the first.

For subscribers in the Boston area, a Level 1 rating means the state will reimburse the insurer $328.36 a month, while a Level 3 rating means a monthly stipend of $2371.40 a month, according to the Attorney General's complaint.

The Attorney General has reviewed audit reports prepared by the Office of Long Term Services and Supports regarding United. The OLTTS audit found that, in a significant portion of the records reviews, United's documentation failed to support its assertion that the MassHealth member required Level 3 care.

In a series of four formal "civil investigative demands" dating to 2022, the state has asked United to produce data and text messages related to how it assigned subscribers needing the most intensive home care, but the company has failed to produce most of the requested information and has not even filed motions seeking to block the state demands, according to the complaint.

As one example, the state says that last November, it asked the insurer for 42 months of internal chat messages related to the company's decisions to place specific subscribers into the most intensive group, but that the company handed over just two months of messages.

The documents not produced by United contain information that is crucial to the MFCA investigation.

The state says it offered United the ability to provide data on a rolling basis rather than all at once, but that at this point, it's no longer willing to negotiate:

United, a national health insurer operating private and public health plans across the country, has not advanced any practical or legal reason for its delay, such that the only plausible reason remaining for its refusal to provide responsive delays is strategic delays.

The state asks a judge to order the company to provide all the requested data and documents within 21 days.

Complete complaint (2.3M PDF).
Legal memorandum to support complaint (770k PDF)

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Comments

I recently qualified for Medicare, even though I have insurance thru my employer. So I did some research.

At first, Advantage plans sound great. The government pays your chosen private health care company a flat amount to handle most/all your costs. And that private company has to cover all costs covered by Medicare. But many of those companies are denying coverage for care costs that regular Medicare would have covered. Hospitals have started not accepting Medicare Advantage patients due to denials of coverage. So if advantage customers want care their Dr. recommends, they may have to pay out of pocket.

A person I work with who had Medicare Advantage, dropped it and signed onto regular Medicare during Medicare's last open enrollment due to coverage issues.

If you or anyone you know is coming of Medicare age, please do your research!

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In Massachusetts you can switch from Medicare Advantage to traditional Medicare and also buy the supplement plan that covers the big gaps Medicare leaves open. In nearly every other state, you can’t buy the supplement after switching back from Medicare Advantage, unless you agree to exempt pre-existing conditions. Very important to remember if you are moving or don’t live in Mass. I believe Wisconsin has the same provision.

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Both Tufts and Blue Cross Blue Shield of Massachusetts offer Medicare Advantage plans.

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what will their shareholders think?

They do a lot of fine lobbying which I support, but they also have what seems to me an unhealthy dependence on United Health, whose plans they aggressively promote over those of any other insurer. I'd recommend using only locally-based non-profit insurers if you choose Medicare Advantage.

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United is constantly pushing its members to accept “house calls,” where they send someone to your home to interview you about health concerns. They tell you it’s a wonderful benefit that helps to inform your doctor of any problems. But I suspect them of using the info primarily to put their clients into a higher cost category and justify billing Medicare for more $. I wouldn’t be surprised if this turns out to be a major part of this complaint.

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"But I suspect them of using the info primarily to put their clients into a higher cost category and justify billing Medicare for more $. "

That's EXACTLY what they are doing. As recent signee to Medicare (and United Health) I can't get rid of these telemarketing calls for this so-called "home health check". I've blocked the number at last three times yet still they somehow get through. One of these shameless telemarketers even said to me "we won't stop calling until you agree to the home health check". Yes, they actually said that. They are very cheeky.

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At least not so far, during the 18 months I've been a member.

Think about it. When you buy fire insurance, the insurance company is betting that you won't have a fire, and most of the time, they'll win. Most people's houses don't catch fire.

But health insurance is different. The insurance company is pretending to bet that you won't get sick, but it knows that sooner or later you will, because we all do.
So the only way the insurance company wins is by cheating, that is, by denying claims.

The Canadians have it right.

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