Benjamin Poehling, former UnitedHealth Group official, said insurance companies have been working the system and taking billion of dollars from the Medicare Advantage system, in an interview with The New York Times.
Here are seven takeaways:
1. He said UnitedHealth and other insurance companies would game the system by having their financial directors run projects that made patients appear sick than they were. These directors would look over patients' EHRs and look at ways they could alter the diagnosis codes.
2. By making patients appear sicker, payers would obtain more money from Medicare Advantage. Mr. Poehling said to NYT, "They've set up a perfect scheme. It was rigged so there was no way they could lose."
3. Mr. Poehling filed a lawsuit under the False Claims Act against UnitedHealth and 14 other companies for these practices, which a federal judge unsealed in February. Mr. Poehling is attempting to recover money for CMS, of which he will receive a portion.
4. Mr. Poehling filed the suit in 2011 and left the company at the end of 2012. NYT reports the lawsuit could speak to why payers participate in the MA program during a time when countless payers are withdrawing their ACA plans.
5. NYT reports the lawsuit's validity rests in whether payers were violating CMS regulations as the government gives payers more money to cover Americans with more serious health problems.
6. A UnitedHealth spokesperson said to NYT, "We are confident our company and our employees complied with the government's Medicare Advantage program rules, and we have been transparent with CMS about our approach under its murky policies."
7. The Justice Department has been investigating various whistleblower cases involving payers like Aetna, Humana, Health new and Bravo Health, a Cigna affiliate. CMS did not comment to the NYT regarding this article.