Whistleblower suits target insurer titan.
It’s been a busy couple of weeks for at least one of the two whistleblower cases proceeding against UnitedHealth Group in federal district court over allegations of Medicare Advantage fraud. I will refer to this case as the Swoben action because it was initiated by whistleblower James Swoben, a former data manager of Scan Health Plans.
To set the stage for these latest developments, let’s begin with a brief review of the recent procedural history of the Swoben case:
On Oct. 5, presiding U.S. District Court Judge John F. Walter issued an order granting United’s motion to dismiss the government’s complaint. Although he dismissed some of the claims with prejudice, for others Judge Walter gave the government leave to amend its complaint to strengthen its allegations.
However, rather than seeking to amend its complaint, on Oct. 12 the United States filed a notice that it was dismissing its claims against the UnitedHealth Group defendants. The dismissal was made without prejudice, which means the government could seek to revive its allegations at a later date.
Last week, on Oct. 18, Mr. Swoben also filed a notice of dismissal – this one seeking to dismiss the remaining defendants in his whistleblower case. Mr. Swoben’s dismissal was made without prejudice as well and preserves his right to later refile. That same day, the United States consented to Swoben’s dismissal of these defendants. The impact of these two dismissals appears to be that there are no longer any active claims in the Swoben case, and the matter is now effectively dismissed.
According to Law360, although the United States has declined to comment on its dismissal in the Swoben matter, a spokesperson for the U.S. Attorney’s Office in Los Angeles did note that the government is still litigating another whistleblower lawsuit in the Central District of California involving allegations of Medicare Advantage fraud. The government joined this lawsuit, which was initiated by whistleblower Benjamin Poehling, in February of this year and filed its complaint-in-intervention in May. Mr. Poehling worked for UnitedHealthcare Medicare and Retirement in Minneapolis on matters involving United’s Medicare Advantage plans. On Sept. 28, presiding Judge Michael W. Fitzgerald denied United’s motion to transfer the case to the District of Columbia, where it is pursuing a case against the Centers for Medicare & Medicaid Services (CMS) under the Administrative Procedures Act.
In short, while the Swoben case appears to have reached its conclusion, the government’s case against UnitedHealth Group with Poehling continues.
The Centers for Medicare & Medicaid Services (CMS) issued the review copy of the Fee Schedule, Friday, Nov. 1. Usually, the final copy appears about
Some of you may have noticed that I am not always very nice to some insurance companies. And deservedly so. But I also point out
Please log in to your account to comment on this article.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.
This webcast, presented by Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, a recognized expert with over 30 years of experience, offers essential strategies to improve outpatient clinical documentation integrity. You will learn how to enhance the accuracy and completeness of patient records by adopting best practices in coding and incorporating Social Determinants of Health (SDOH). The session also highlights the role of technology, such as EHRs and CDI software, in improving documentation quality. By attending, you will gain practical insights into ensuring precise and compliant documentation, supporting patient care, and optimizing reimbursement. This webcast is crucial for those looking to address documentation gaps and elevate their coding practices.
ICD10monitor has teamed up with renowned CDI expert Dr. Erica Remer to bring you an exclusive webcast on how to recognize sepsis, how to get providers to give documentation that will support sepsis, and how to educate to avert sepsis denials. Register now and become a crucial piece of the solution to standardizing sepsis clinical practice, documentation, and coding at your facility.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.
Copyright © 2024 RACmonitor. Powered by MedLearn Media.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
👻Spooky Sale is Back!👻 Get 31% off all three Medlearn brands, using code SPOOKY24.
