Overview
- Senate Judiciary Chair Chuck Grassley released the report after reviewing roughly 50,000 records UnitedHealth provided to investigators.
- Investigators say UnitedHealth drove higher risk scores through home nurse visits, secondary chart reviews, paid external assessments and AI-guided workflows, and captured more diagnoses than peers, increasing CMS reimbursements.
- The report cites guidance that could inflate coding, including labeling prescribed-opioid users as opioid dependent, diagnosing dementia or COPD without standard evaluations, and flagging atrial fibrillation based on medications.
- UnitedHealth disputes the characterization, saying its Medicare Advantage programs comply with CMS requirements and have demonstrated adherence in government audits.
- Oversight pressure is building as DOJ civil and criminal probes continue and House committees plan to question major insurer CEOs on Jan. 22.