Massachusetts AG Sues UnitedHealthcare for $100M MassHealth Risk Score Fraud
The Massachusetts Attorney General filed suit against UnitedHealthcare alleging the insurer improperly inflated health risk scores for MassHealth members to obtain at least $100 million in excess capitation payments. The complaint accuses UnitedHealthcare of manipulating diagnosis coding to secure higher risk-adjusted payments from the state Medicaid program. The lawsuit seeks recovery of overpayments and penalties. This case signals increased state enforcement of risk adjustment integrity in Medicaid managed care and may prompt heightened scrutiny of diagnosis coding practices and chart review audits across other states.
This lawsuit demonstrates that state attorneys general are actively pursuing Medicaid managed care organizations for alleged risk adjustment gaming, creating significant financial and compliance exposure for plans that fail to maintain defensible diagnosis coding and risk score documentation practices.
Managed Care · Finance
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