Massachusetts Sues UnitedHealthcare Over $100 Million MassHealth Fraud in Senior Care Plan
Updated
Updated · WBUR News · May 29
Massachusetts Sues UnitedHealthcare Over $100 Million MassHealth Fraud in Senior Care Plan
10 articles · Updated · WBUR News · May 29
At least $100 million in alleged overpayments is at the center of Massachusetts Attorney General Andrea Campbell's lawsuit accusing UnitedHealthcare of defrauding MassHealth through its Senior Care Options plan for members 65 and older.
The complaint says United manipulated health assessments to place seniors in higher-paying care levels, including Level 2 classifications without behavioral health or substance-use diagnoses and Level 3 designations for members who did not qualify.
Campbell's office also alleges United submitted assessments claiming members needed daily skilled nursing services even though most did not need or receive that care, and failed to disclose or repay inflated payments after internal reviews found Level 3 errors.
United called the suit meritless, saying the complaint misstates a program designed to support seniors with complex care needs and arguing the attorney general is wrong to challenge those services.
The case lands as MassHealth, which is slated to receive about $22 billion in fiscal 2027, faces pressure to cut spending amid looming federal funding reductions.
Beyond the $100M, what was the hidden cost to elderly patients whose care plans were falsified?
If insurers profit by labeling seniors as sicker, is the entire payment system designed to fail patients?
Could AI be the ultimate watchdog to stop insurers from overbilling the government for your healthcare?
$100 Million Medicaid Fraud Lawsuit: Massachusetts Targets UnitedHealthcare for Upcoding in Senior Care Options Program
Overview
Massachusetts has filed a major lawsuit against UnitedHealthcare, accusing the insurer of widespread Medicaid fraud by exaggerating the health conditions of elderly, low-income patients to receive higher state payments. The case centers on the Senior Care Options program, where UnitedHealthcare allegedly understaffed nurses and pressured them to assign higher care levels, boosting profits through upcoding. These actions, driven by internal incentives and a 'growth-at-all-costs' strategy, led to false claims and abandoned quality controls. The lawsuit highlights systemic flaws in risk-adjusted payment systems, threatens UnitedHealthcare’s reputation, and could spark broader industry reforms and increased regulatory scrutiny nationwide.