The Massachusetts attorney general has filed a lawsuit against UnitedHealthcare, accusing the insurance giant of fraudulently inflating health risk scores to obtain excess payments.
The suit alleges that UnitedHealthcare improperly manipulated the health risk scores of MassHealth members in order to secure financial gains from the state programme.
According to the attorney general, the scheme resulted in UnitedHealthcare receiving at least $100 million in payments it was not entitled to collect.
MassHealth is Massachusetts’ Medicaid programme, providing health coverage to low-income residents across the state, and its funding draws significantly from public resources.
Health risk scores are used to determine how much insurers are paid to cover patients, with higher scores indicating sicker patients and generating larger reimbursements.
The attorney general’s office contends that UnitedHealthcare deliberately inflated these scores beyond what members’ actual health conditions would justify.
By doing so, the insurer allegedly triggered higher reimbursement rates that did not accurately reflect the true medical needs of the MassHealth population it was serving.
The lawsuit represents one of the more significant legal actions taken against a major insurer in Massachusetts in recent years, given the scale of the alleged overpayments.
UnitedHealthcare (UNH) is one of the largest health insurers in the United States, operating across a broad range of government-sponsored and commercial health programmes nationwide.
The outcome of this case could have considerable implications for how risk score accuracy and Medicaid billing practices are scrutinised by state authorities going forward.
The Massachusetts attorney general’s action signals an increasingly aggressive posture by state regulators toward large insurers operating within publicly funded health coverage programmes.