Literature Review

Ohio payer beats UnitedHealthcare in racketeering lawsuit, awarded $50M Becker's Payer Issues; by Jakob Emerson; 3/19/25 An Ohio jury awarded Medical Mutual of Ohio over $50 million in damages on March 12 after the payer prevailed in its lawsuit against FrontPath Health Coalition and HealthScope Benefits, a subsidiary of UnitedHealthcare. FrontPath offers employee benefits solutions, and HealthScope is a third-party administrator. .. The defendants were found to have committed federal wire fraud, telecommunications fraud, tampered with records, and obstructed justice by submitting false bid information. The jury found that the conspiracy resulted in significant damages to Medical Mutual and ultimately caused taxpayers to pay higher healthcare costs than necessary.

Lancaster woman convicted in hospice fraud schemeNBC-4 News, Los Angeles, CA; by City News Service; 3/21/25 A Lancaster [California] woman was found guilty Friday of receiving more than $330,000 in illegal kickbacks for patient referrals to two hospice companies in a fraud scheme that bilked Medicare out of more than $3.2 million through claims for medically unnecessary services. Callie Jean Black, 66, was convicted at the conclusion of a four-day bench trial in Los Angeles federal court of four counts of soliciting and receiving remunerations for patient referrals, according to the U.S. Attorney's Office. U.S. District Judge André Birotte Jr. scheduled sentencing for July 25. [Continue reading ...] 

Hospice worker accused of exploiting patient, steals $7K CBS12 News, Tampa, FL; by Skyler Shepard; 3/12/25 A hospice worker is accused of financially exploiting a hospice patient under her care. The Hillsborough County Sheriff's Office (HCSO) said deputies responded to a delayed fraud report on March 4 on Clubhouse Circle, where the victim, receiving hospice care, reported being defrauded by a home health assistant. The sheriff's office said the fraudulent activity reportedly began on January 28. The suspect, identified as Shawn Livingston, allegedly persuaded the victim to use Zelle for service payments and manipulated the transactions to transfer money to her accounts, pay her creditors, and make payments to Carnival Cruises, stealing more than $7,000. On March 7, deputies arrested the 57-year-old woman, who now faces exploitation of an elderly person, fraudulent use of personal information, grand theft, fraudulent use of a credit card, and uttering a forged instrument.

DOJ launches probe into UnitedHealth’s Medicare billing practices after investigative reports MSN; by Taylor Herzlich; 3/22/25 The Department of Justice has reportedly launched an investigation into UnitedHealth Group’s Medicare billing practices as scrutiny over the health insurance industry intensifies — sending the company’s stock plummeting.The probe is analyzing the company’s practice of frequently logging diagnoses that trigger larger payments to its Medicare Advantage plans, according to The Wall Street Journal. UnitedHealth shares plunged nearly 9% Friday. A series of Wall Street Journal reports last year found that Medicare paid UnitedHealth billions of dollars for questionable diagnoses.

Class action over UHG's alleged AI-driven care denials advances Modern Healthcare; by Lauren Berryman; 2/13/25 A class action regarding UnitedHealthcare’s alleged use of artificial intelligence to deny care for Medicare Advantage members will continue playing out in court, but with fewer claims. In a court filing Thursday, a federal judge said two of seven claims brought against UnitedHealth Group by health plan members and their families — who alleged the company used AI to deny coverage for medically necessary post-acute care — can move forward. UnitedHealth Group has been battling the lawsuit, filed in the U.S. District Court for the District of Minnesota, since November 2023. Plaintiffs have alleged the company's health insurance unit UnitedHealthcare used an AI tool called nH Predict to make coverage decisions, sometimes overriding physician judgment. 

UnitedHealth drops dismissal bid in US suit over Amedisys deal Bloomberg Law; by Justin Wise; 2/6/25 (additional subscription may be required)UnitedHealth Group Inc. is withdrawing its motion to dismiss the Justice Department’s lawsuit seeking to block its $3.3 billion acquisition of home-health and hospice services provider Amedisys Inc. and planning to fight the case at trial. In a Wednesday [2/5/25] filing in the US District Court for the District of Maryland, UnitedHealth and Amedisys said that new information provided by the Justice Department eliminated the basis for its request to toss the case at a preliminary stage. The firms previously argued the DOJ was withholding key geographic market information integral to its claim that the tie-up would stifle competition ...