News: UnitedHealth Group used ‘aggressive strategies’ to maximize MA payments, Senate report says

UnitedHealth Group (UHG) used “aggressive strategies” to increase its Medicare Advantage (MA) risk adjustment scores and collect higher payments from MA enrollees’ diagnoses, according to a new Senate Judiciary Committee report.

The report says that some Medicare Advantage organizations (MAO) are considered “coding intensive” because they have the resources and “superior” strategies to capture diagnoses and codes that lead to higher risk adjustment scores; other MAOs may have fewer resources or other priorities that lead them to be less coding intensive and therefore receive lower risk adjustment payments.

“While much of this coding intensity is likely clinically appropriate (e.g. MAOs with more resources are able to capture more diagnosis codes), there have been concerns that some of this coding intensity is not (i.e. gaming),” the report says.

Following reports that UHG was coding more intensively than its peers in 2024, a request was filed for information about the practices UHG uses to capture MA enrollee diagnoses. Upon reviewing the requested documentation—totaling more than 50,000 pages of internal training materials, policies, software documentation, and audit tools, according to the Senate Judiciary Committee report—the committee found that the evidence “shows UHG has turned risk adjustment into a major profit centered strategy, which was not the original intent of the program.”

Specifically, the report says that UHG has

• “…a robust diagnosis capture workforce […] and uses its advanced data assets and data analytics capabilities to maximize its workforce’s ability to capture diagnoses.”
• “…identified opportunities and strategies to increase its capture of untapped risk score garnering diagnoses and has used its robust provider workforce to implement those strategies.”

The Senate Judiciary Committee, according to the report, will continue to evaluate the information provided by UHG.

“MAOs should receive payments that are commensurate to the complexity and acuity of the Medicare beneficiaries that they insure, not their knowledge of coding rules and their ability to find new ways to expand inclusion criteria for diagnoses,” the report concludes. “Taxpayers and patients deserve accurate and clear-cut risk adjustment policies and processes.”

Editor’s note: To read the Senate Judiciary Committee report, click here. To read the coverage from the American Hospital Association, click here.