Allegations have been mounting that private insurance companies take advantage of the Medicare Advantage, or Part C, program — at high cost to the federal government (and thus, to taxpayers).

U.S. Sen. Chuck Grassley, R-Iowa, sent a letter to one of the largest healthcare organizations in the world, UnitedHealth Group, demanding details about the company’s Medicare billing practices. He wrote that, for the past decade, he has been urging the Centers for Medicare & Medicaid Services and the Department of Justice to recover improper payments made to UnitedHealth and other Medicare Advantage Organizations (MAOs). (UnitedHealth denies wrongdoing.)

“Despite these oversight efforts,” Grassley wrote, “MAOs continue to defraud the American taxpayer, costing them billions of dollars a year.”

The pressure has been mounting:

• On Feb. 21, The Wall Street Journal broke the news that the Department of Justice was investigating UnitedHealth’s Medicare Advantage billing practices. CNBC offers a recap of the company’s rough past year, much of it sparked by WSJ reporting.
• An analysis of billions of Medicare records by The Wall Street Journal found private insurers made “hundreds of thousands of questionable diagnoses that triggered extra taxpayer-funded” Medicare Part C payments from 2018-2021.
• In September, the U.S. Department of Health and Human Services’ Office of Inspector General issued a report raising similar concerns. The OIG found that 20 of the country’s 162 MA companies accounted for a disproportionate share of $9.2 billion in payments from diagnoses that were only reported on chart reviews and health risk assessments.
• A month later, an inspector general audit revealed that in 2023, MAOs received $7.5 billion from diagnosing health conditions that didn’t require medical services. About $4.2 billion of that total came through home health assessments, leading the watchdog to suggest limiting these visits. (Read more in The Washington Post.) 
• A December report in The Wall Street Journal found that MAOs collected billions of dollars in premiums for veterans who typically go to the Department of Veterans Affairs for healthcare services. Some of these MAOs have begun offering plans specifically branded to veterans. Effectively, the report said, the federal government ends up paying twice for veterans’ health care needs — for the care the VA provides, and for the extra insurance premiums.
• Similarly, a study found that in 2020, CMS paid more than $1.32 billion to Medicare Advantage plans that included VA enrollees who did not use any Medicare services.
• A CVS subsidiary recently struck a $60 million settlement to resolve kickback allegations. The subsidiary allegedly paid third-party insurance agents to recruit to its primary care clinics seniors who were either eligible for or enrolled in Medicare Advantage, regardless of the seniors’ best interests.

There’s been other pressure, too: The Federal Trade Commission sued three drug middlemen (owned by large insurers) in September, alleging anticompetitive and unfair rebating practices that inflated insulin prices.

The existence of Medicare Advantage fraud already has been established; whistleblowers are needed to help root it out and protect taxpayers. For fiscal 2024, the DOJ announced more than $2.9 billion in settlements connected to fraud against the federal government, with over $1.67 billion of the total stemming from healthcare fraud.

The federal False Claims Act incentivizes whistleblowers to report fraud against the government by rewarding them with a percentage of the amount the government recovers as a result of the whistleblower’s case. According to the Taxpayers Against Fraud Education Fund, between 2010 and 2020, the government’s FCA recoveries totaled $40.2 billion. Of that total, about 68 percent came from healthcare-related recoveries.

Keller Grover represented a whistleblower in a landmark $90 million settlement against Sutter Health over allegations that the organization committed massive Medicare Advantage fraud over a six-year period. 

If you know something about fraud against the government, you could help stem the tidal wave of fraud. Keller Grover often helps those who suspect wrongdoing, providing confidential, free consultations. We work with potential whistleblowers from the very beginning to find the best path forward, help minimize the impact of reporting, consider potential rewards, protect their rights, and achieve the best possible outcomes.