UnitedHealth Group has confirmed it is under investigation by the DOJ. For healthcare leaders, the multiple probes into the payer could signal potential for a significant shift in payer-provider relationships ahead.
UnitedHealth Group confirmed in a recent regulatory filing that it is under investigation by the Department of Justice (DOJ), and that it is complying with criminal and civil requests.
In May, the Wall Street Journal reported that the DOJ criminal division had launched an investigation into the health insurance behemoth. A UnitedHealth statement issued at the time said the company was unaware of a criminal investigation.
"The WSJ's reporting is deeply irresponsible, as even it admits that the 'exact nature of the potential criminal allegations is unclear'," the statement read. "We stand by the integrity of our Medicare Advantage program."
Earlier reporting suggested the DOJ was investigating UnitedHealth for potential antitrust violations and that a separate civil fraud investigation was looking into potential upcoding at the company.
Does UnitedHealth give preferential treatment to its affiliated provider groups?
One component of the investigation into UnitedHealth is a broad antitrust probe examining the relationship between UnitedHealth's insurance business, UnitedHealthcare, and its health services subsidiary, Optum.
The question here is whether UnitedHealth is unfairly favoring Optum-owned and -affiliated provider groups, which includes tens of thousands of physicians nationwide. These accusations imply UnitedHealth is engaged in anti-competitive behavior that impacts independent providers and unaffiliated health systems.
Has UnitedHealth deceived the government by engaging in upcoding?
The other component of the investigation, which may have more significant implications for healthcare executives, is looking into allegations of upcoding – the practice of submitting diagnoses that are not supported by medical records to receive inflated risk-adjusted payments from the federal government.
UnitedHealth has been fighting allegations of upcoding for more than a decade. In 2011, Benjamin Poehling, a former UnitedHealth employee, launched a civil fraud case accusing the company of misrepresenting the medical conditions of beneficiaries. The DOJ took over the case in 2017, KFF Health News reported.
However, that case stalled earlier this year when a court-appointed special master in the case, Suzanne Segal, determined that DOJ had not submitted evidence sufficient enough to support its claim.
What it means for healthcare leaders
While investigations are focused on UnitedHealth, ripple effects will be felt through the broader healthcare industry. The company will likely ramp up its own internal audits and claim reviews to mitigate its legal and financial risk. Any policy changes at UnitedHealth, which accounted for 29% of all Medicare Advantage enrollment in 2024, will affect virtually all providers. These changes could manifest as even higher volumes of claim denials, lower tolerance for coding inconsistencies, and increased requests for information.
Additionally, heightened scrutiny on the payer could create a tense environment for contract negotiations, especially for providers competing with Optum-owned and -affiliated physician groups. As UnitedHealth navigates its significant legal and financial challenges, healthcare leaders should prepare for a rocky reimbursement landscape ahead.
Luke Gale is the revenue cycle editor for HealthLeaders.
KEY TAKEAWAYS
DOJ is conducting multiple investigations into UnitedHealth and the company confirmed earlier reporting that one of these probes is being conducted by criminal investigators.
While UnitedHealth is the target, providers should anticipate downstream effects, which could include higher volumes of claim denials and more requests for information.
The heightened scrutiny could also create a more tense environment for contract negotiations with UnitedHealth, which accounts for nearly a third of Medicare Advantage enrollees nationwide.