Massachusetts AG Sues UnitedHealthcare for $100M MassHealth Risk Score Fraud
The Massachusetts Attorney General filed suit against UnitedHealthcare alleging the insurer improperly inflated risk scores for MassHealth members to secure at least $100 million in excess capitation payments. The complaint accuses UnitedHealthcare of systematically manipulating diagnosis codes to increase member acuity scores beyond what clinical documentation supported. The lawsuit seeks repayment of fraudulent payments plus penalties. This case follows growing scrutiny of risk adjustment practices across Medicare Advantage and Medicaid managed care programs.
The case signals intensified state enforcement of risk adjustment integrity and could prompt audits of MCO diagnosis coding practices in other states where capitation rates are tied to member acuity scores.
Managed Care · Finance
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