Massachusetts alleges the insurer manipulated patient assessments to secure excessive Medicaid payments for senior care plans.
Massachusetts Attorney General Andrea Joy Campbell sued UnitedHealthcare for allegedly defrauding the state’s Medicaid program, MassHealth, by inflating patient care levels to obtain higher payments. The lawsuit claims the insurer overcharged MassHealth by at least $100m through its Senior Care Options plan, which covers eligible residents aged 65 and above.
The Senior Care Options program requires enrollees to undergo in-home clinical reviews to determine care bands, with Level 3 carrying the highest payment rate. UnitedHealthcare, the largest provider of these plans in Massachusetts, is accused of misrepresenting members’ health conditions, including improperly placing patients in higher-cost categories.
The Attorney General’s Office stated the alleged fraud involved manipulating assessments for behavioral health or substance use disorder categories. Campbell emphasized the state’s commitment to holding companies accountable for exploiting vulnerable residents and misusing taxpayer funds.