By: Christopher Parrella, Esq., CPC, CHC, CPCO
Parrella Health Law, Boston, MA.
A Health Care Provider Defense and Compliance Firm

In a move that has begun to send shockwaves through the Medicare Advantage (MA) space, UnitedHealth Group, the nation’s largest private health insurer confirmed that it is now the subject of both criminal and civil investigations by the Department of Justice (DOJ) over its Medicare billing practices.

UnitedHealth revealed in a July 24 securities filing that it is cooperating with the DOJ and has launched a third-party review of its own policies and performance metrics. The investigation, reportedly focused on diagnosis coding and risk adjustment within its MA plans, raises the stakes not only for United but for providers whose payments—and audit exposure—are tied to the MA model.

Why This Matters to Providers

UnitedHealthcare’s MA business generates more than $139 billion in annual revenue. Its financial strength is built, in part, on diagnosis codes submitted by contracted providers, codes that determine patient risk scores and, ultimately, federal reimbursement.

If DOJ investigators find systemic overcoding, pressure tactics on physicians, or inappropriate risk adjustment submissions, providers may find themselves pulled into the enforcement net particularly if their records are inconsistent with the claims submitted in their name.

What’s reportedly under investigation:

• Whether doctors were pressured to submit diagnosis codes that boosted MA plan payments.
• Whether UnitedHealth manipulated risk adjustment to inflate revenue.
• Whether some conditions coded lacked clinical documentation or weren’t actively treated.

Enforcement Backdrop: The Risk Adjustment Reckoning

This isn’t DOJ’s first pass at MA scrutiny. In February and again in July, the Wall Street Journal reported that federal prosecutors interviewed physicians about whether they felt pushed by United to “find” diagnoses that raised risk scores. Earlier DOJ civil investigations were also probing potential “upcoding” practices (billing for higher-severity conditions than what was documented or clinically justified.)

While United has long defended the integrity of its MA program, the company has now formally acknowledged DOJ inquiries, a rare step for a corporation of its size. The change in tone coincides with recent leadership turnover, including the sudden resignation of CEO Andrew Witty and the company’s suspension of its 2025 earnings forecast.

Key Takeaways for Our Clients

If you are a behavioral health group, physician practice, or post-acute provider that contracts with MA plans, especially UnitedHealthcare, you should take this opportunity to reevaluate your risk adjustment compliance posture.

Chart-to-Claim Validation Audits: Review diagnoses submitted to United and other MA plans against clinical documentation. If conditions weren’t documented or treated, they shouldn’t be coded.

Staff Training: Ensure coders and billers understand the difference between historical diagnoses and active conditions. Coders should never infer diagnoses from incomplete documentation.

Review Risk Score Submissions: If your practice participates in chart reviews or health assessments sponsored by United or another plan, make sure any risk score contributions are traceable to clinical necessity.

Watch for Broker Pressure: Improper steering of patients or incentives tied to MA enrollment (a separate focus of recent DOJ suits) can also expose providers to Anti-Kickback Statute risks.

What Comes Next?

While United maintains that CMS audits show its practices are “among the most accurate in the industry,” the DOJ’s escalation signals that the feds are not backing off MA plan scrutiny. As CMS moves to finalize long-debated risk adjustment reforms and civil litigation against major MA players mounts, more False Claims Act cases tied to Medicare Advantage are expected in the months ahead.

If you’re concerned about your exposure under a United contract or any MA contract we’re here to help you conduct internal audits, prepare a defensible coding policy, and proactively address compliance gaps. Contact Parrella Health Law at 857.328.0382 or email Chris directly at cparrella@parrellahealthlaw.com