United Probe Expansive
The U.S. Justice Department’s (DOJ) criminal division investigation into UnitedHealth Group has been bigger from the start or has expanded. Latest reports suggest that the company is under investigation into both how it reimburses its owned doctors as well as its pharmacy benefit’s manager’s (PBM — OptumRx) business and billing practices. Previously, it was reported the DOJ was investigating alleged Medicare Advantage (MA) risk adjustment fraud.
In the past, I have talked about how federal regulators might go after vertical integration in the healthcare industry and United is the biggest example. Vertically integrated companies are alleged to unfairly inflate price/cost and skirt the minimum medical loss ratio (MLR) rules by having non-arm’s-length agreements with their related companies to keep revenue and margin within the overall enterprise. Could the PBM and physician investigations be touching this concept? It could also be the case that the incentives given owned doctors as well as other pricing and relationships by the PBM violate fraud and other laws.
Additional articles: https://www.modernhealthcare.com/insurance/mh-doj-unitedhealth-optum-rx-medicare-billing/ and https://www.fiercehealthcare.com/payers/wsj-report-doj-interviewing-former-employees-about-medicare-billing-practices-unitedhealth
#fwa #unitedhealthcare #medicareadvantage #doj #antitrust