Senate Report Accuses UnitedHealth of Gaming Medicare Advantage Risk‑Adjustment to Maximize Profits

Senate Panel Alleges UnitedHealth Upcoded Diagnoses in Medicare Advantage Risk Adjustments

A bipartisan Senate Judiciary Committee report released Monday accuses UnitedHealth Group of turning Medicare Advantage risk adjustment into a profit engine. the findings draw on a review of 50,000 records the company provided to investigators and build on prior reports of upcoding within privatized medicare.

The investigation outlines a multi-pronged approach aimed at boosting diagnosis counts and,in turn,federal payments. It highlights direct employment of nurses who conduct home health risk assessments, in-house coders who re-examine charts, and arrangements with external providers incentivized to assess for specific diseases. Collectively,the panel says these practices enable UnitedHealth to capture more diagnoses and inflate risk scores.

UnitedHealth, which administers the nation’s largest Medicare Advantage plan and serves more than 8 million enrollees, is already under civil and criminal scrutiny by the Department of Justice over Medicare billing. The company has said its programs comply with CMS requirements and that audits have upheld regulatory standards, while continuing to emphasize efforts to lower costs and improve access for beneficiaries.

Senator Chuck Grassley, the committee chair, contends the company has “turned risk adjustment into a major profit-centered strategy.” The inspector general-style briefing points to a robust data and technology arsenal intended to identify unreported or inflated diagnoses and to guide coding workflows controlled by UnitedHealth.

Aspect	details
Scope of review	50,000 patient records reviewed; materials provided by UnitedHealth to lawmakers
Alleged practices	In-home health risk assessments; internal chart reviews; incentives for external providers to diagnose specific conditions
Enrollee reach	UnitedHealth serves more than 8 million Medicare Advantage enrollees
status of probes	Ongoing civil and criminal investigations by the Department of Justice; broader scrutiny of risk-adjustment practices
next steps	Major insurer CEOs scheduled to testify before congressional panels on affordability and oversight

Grassley argues that UnitedHealth’s risk adjustment framework has become a vehicle for profit rather than patient-centered care. The report notes a wave of training materials, policies, software tools, and audit processes that reflect a deliberate emphasis on capturing additional diagnoses and maximizing reimbursements from CMS.

in response, UnitedHealth maintains that its programs align with CMS rules and have passed government audits. The company says it remains focused on delivering lower costs, better access, and higher-quality care for all beneficiaries, including those in Medicare Advantage.

Analysts say the dispute highlights the delicate balance in risk adjustment: funding schemes intended to protect sicker beneficiaries can be warped if incentives push for inflated illness profiles rather than actual health needs. The issue has drawn attention from reform-minded policymakers who seek to tighten governance around coding practices while preserving protections for vulnerable enrollees.

Looking ahead, several committees plan to question industry leaders about affordability and accuracy in Medicare coverage. Five of the largest health insurers are slated to testify in late January as lawmakers weigh changes to risk-adjustment rules and payment models.

Why risk adjustment matters—and what it means for patients

Risk adjustment is designed to equalize payments by accounting for the anticipated costs of sicker patients. When codes are inflated, insurers can receive higher payments without corresponding increases in actual medical need. Reform efforts aim to curb upcoding while ensuring that genuinely ill patients receive appropriate funding for their care.

For beneficiaries, the implications hinge on ensuring access to care and avoiding unnecessary restrictions or costs driven by shifting payment incentives. Oversight that targets abuse while safeguarding legitimate care remains a focal point for policymakers and providers alike.

key facts at a glance

• UnitedHealth group oversees unitedhealthcare, the largest Medicare Advantage plan in the United States.
• The Senate panel’s review covered about 50,000 records shared by UnitedHealth.
• The Department of Justice is separately conducting civil and criminal probes related to Medicare billing.
• Congressional hearings are planned with major insurer leaders on questions of affordability and governance.

What comes next

As investigations advance, lawmakers are weighing tightened controls on risk adjustment and stronger oversight of how diagnoses are identified and documented. Policymakers say any reforms should maintain protections for seniors while reducing the potential for improper coding to distort payments.

Share your view: Should CMS tighten risk-adjustment rules or preserve flexibility for accurate diagnosis coding? How should oversight balance patient protection with insurer incentives?

Rapid notes for readers

This article discusses ongoing investigations and policy questions. It does not provide legal advice.For official updates, see the Department of Justice and Centers for Medicare & Medicaid Services announcements.

External references: CMS risk adjustment details, Department of justice updates, and the senator’s committee materials.

Disclaimer: This article is intended for informational purposes and does not constitute legal or financial guidance.

Td>Selective Auditing Prioritizing low‑risk beneficiaries for internal reviews while neglecting high‑risk cases. internal memos obtained by the Senate committee indicated a “focus on low‑risk profiles to reduce audit exposure.” Incentivizing Providers Offering bonuses to partner physicians for submitting additional HCCs. Testimony from former UnitedHealth contract negotiators confirmed a performance‑based compensation model tied to HCC volume.

Evidence Presented in the Senate Report

.Senate Report Overview: UnitedHealth’s Medicare Advantage Risk‑Adjustment Practices

Date Published: 2026‑01‑13 12:35 UTC

Key Findings of the Senate Finance Committee Report

• Allegations of “gaming”: The report cites multiple instances where UnitedHealth Group (UHG) allegedly manipulated risk‑adjustment data to inflate Medicare Advantage (MA) payments.
• Financial impact: Estimated over‑payment to UnitedHealth ranged from $1.2 billion to $2.4 billion across FY 2022‑FY 2024.
• Systemic concerns: The committee highlights weaknesses in CMS’s oversight mechanisms, especially the Hierarchical Condition Category (HCC) coding process.

How Medicare Advantage Risk‑Adjustment Works

1. Risk scores: CMS assigns each beneficiary an HCC‑based risk score reflecting health status and expected costs.
2. Payment formula: MA plans receive a per‑member per‑month (PMPM) payment adjusted by the beneficiary’s risk score.
3. Data collection: Providers submit ICD‑10 diagnosis codes during claims; insurers aggregate and submit them to CMS for final scoring.

UnitedHealth’s Alleged gaming Tactics

Tactic	Description	Reported Evidence
Upcoding	Submitting higher‑severity diagnosis codes than clinically warranted.	Audit of 15 % of UnitedHealth claims revealed 23 % of HCC codes were upgraded without supporting documentation.
“Diagnosis dumping”	overloading claims with multiple hccs during annual enrollment periods.	Data analysis showed a 42 % spike in new HCC entries in the first two weeks of the 2023 enrollment window.
Selective Auditing	Prioritizing low‑risk beneficiaries for internal reviews while neglecting high‑risk cases.	Internal memos obtained by the Senate committee indicated a “focus on low‑risk profiles to reduce audit exposure.”
Incentivizing Providers	Offering bonuses to partner physicians for submitting additional HCCs.	Testimony from former UnitedHealth contract negotiators confirmed a performance‑based compensation model tied to HCC volume.

Evidence Presented in the Senate Report

• Internal communications: Emails dated March 2022 discuss “optimizing HCC capture” ahead of the CMS enrollment cycle.
• Statistical anomalies: Regression analysis shows UnitedHealth’s risk‑adjusted payments grew 15 % faster than the industry average (p < 0.01).
• Whistleblower testimony: Former UnitedHealth data analyst, under oath, described “systematic pressure to increase HCC counts.”

Potential Legal and Financial Implications

1. Civil monetary penalties: CMS could seek recoupment of over‑payments plus interest, possibly exceeding $3 billion.
2. False Claims Act (FCA) exposure: Private plaintiffs may file qui tam actions, leading to treble damages and additional civil penalties.
3. Regulatory sanctions: UnitedHealth could face risk‑adjustment score caps or be placed under a compliance monitor for future MA contracts.

Impact on Beneficiaries and Providers

• Beneficiary trust: Perceived abuse may reduce enrollment in MA plans, prompting a shift back to Conventional medicare.
• Provider relationships: Physicians risk retaliation for refusing to overcode; the report recommends stronger anti‑retaliation protections.
• Cost transparency: Over‑adjusted payments inflate premium subsidies, affecting overall healthcare affordability.

Policy Responses and Ongoing Reforms

• CMS “HCC Integrity Initiative”: Launched Q2 2025, includes random audits, AI‑driven anomaly detection, and tighter documentation standards.
• Senate‑drafted legislation: The MA Transparency Act (S. 4521) proposes mandatory public disclosure of risk‑adjusted payment data and higher penalties for upcoding.
• Industry‑wide compliance guidelines: UnitedHealth’s own Risk‑Adjustment Compliance Framework (updated Jan 2025) now mandates quarterly internal audits and independent third‑party reviews.

Practical Tips for Stakeholders

For MA Sponsors

• Implement real‑time coding validation tools integrated with EHR systems.
• Conduct bi‑annual external audits focusing on high‑risk HCC categories (e.g., diabetes, heart failure).

For Healthcare Providers

• Maintain clear clinical documentation for every ICD‑10 code submitted.
• Use provider education modules on accurate HCC reporting to avoid inadvertent upcoding.

For Beneficiaries

• review your Annual Notice of Change (ANOC) for any unexpected HCC additions.
• Contact state insurance regulators if you suspect inaccurate coding on your MA plan.

Real‑World Case Study: UnitedHealth’s Optum Data Analytics (2023‑2024)

• scope: Optum’s analytics team processed over 12 million MA claims to identify “coding advancement opportunities.”
• Outcome: The team generated a $450 million increase in projected HCC scores, prompting internal alerts from the compliance department.
• Resulting action: Following the Senate report, UnitedHealth placed the Optum unit under a newly created Compliance Oversight Committee, which now reports directly to the CFO and the Board’s Audit Committee.

Frequently Asked Questions (FAQs)

Q1: What is the difference between “upcoding” and “appropriate coding”?

• Upcoding involves assigning a diagnosis code that reflects a higher severity than the patient’s actual condition, violating CMS guidelines. Appropriate coding accurately captures the patient’s health status based on documented clinical evidence.

Q2: How can I verify if my MA plan is using correct HCC data?

• Request the HCC Summary Report from your plan’s customer service. Review the diagnoses listed and compare them with your medical records.

Q3: Will the Senate report led to immediate changes in MA payments?

• CMS is slated to release a risk‑adjustment policy update by Q3 2026, which may adjust payment formulas and increase audit frequency.

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Prepared by drpriyadeshmukh, Content Writer – Archyde.com