Grassley Pushes for Answers on UnitedHealth Group’s Medicare Advantage Billing Practices

Read more from the Wall Street Journal HERE

WASHINGTON – Sen. Chuck Grassley (R-Iowa), Chairman of the Senate Judiciary Committee and a former Chairman of the Senate Finance Committee, sent a letter to UnitedHealth Group Chief Executive Officer Andrew Witty demanding detailed information on the company’s Medicare billing practices.

Grassley’s letter cited reports of apparent fraud, waste and abuse at UnitedHealth Group, including efforts to diagnose enrollees with obscure revenue-generating diagnoses that were irrelevant or inaccurate. According to reporting, this resulted in $8.7 billion in extra payments in 2021 alone.

“Despite these oversight efforts, [Medicare Advantage Organizations] continue to defraud the American taxpayer, costing them billions of dollars a year … The apparent fraud, waste, and abuse at issue is simply unacceptable and harms not only Medicare beneficiaries, but also the American taxpayer,” Grassley wrote.

In the letter, Grassley requested UnitedHealth provide its training manuals, guidance documents, compliance program details, audit results and other documents.

Since 2015, Grassley has pressed the Centers for Medicare & Medicaid Services and the Department of Justice to recover improper payments made to Medicare Advantage Organizations, including UnitedHealth Group.

Text of the letter to UnitedHealth Group follows:

February 24, 2025

VIA ELECTRONIC TRANSMISSION

Mr. Andrew Witty

Chief Executive Officer

UnitedHealth Group, Inc.

Dear Mr. Witty:

Twenty-five years ago, I helped shepherd Medicare Part C into law, and I have repeatedly advocated for the program.^[1]  Further, since 2015, I have pressed the Centers for Medicare & Medicaid Services (CMS) and the Department of Justice (DOJ) to recover improper payments made to Medicare Advantage Organizations (MAO), including UnitedHealth Group.^[2]  Despite these oversight efforts, MAOs continue to defraud the American taxpayer, costing them billions of dollars a year.^[3] 

On February 21, 2025, the Wall Street Journal published an article titled, “DOJ Investigates Medicare Billing Practices at UnitedHealth,” which reported that the DOJ launched an investigation into UnitedHealth Group’s Medicare billing practices.^[4]  According to the Journal, UnitedHealth Group used in-home health risk assessments (HRA) and chart reviews to diagnose enrollees with obscure revenue-generating diagnoses that were irrelevant or inaccurate.^[5]  Further, according to the reporting, the inappropriate diagnoses resulted in extra payments of $8.7 billion in just 2021.^[6] 

On October 24, 2024, the Health and Human Services Office of Inspector General (HHS OIG) released a report titled, Medicare Advantage: Questionable Use of Health Risk Assessments Continues To Drive Up Payments to Plans by Billions.^[7]  The HHS OIG found that UnitedHealth Group received more money from CMS for diagnoses only made during in-home HRAs and chart reviews than any other MAO.^[8]  The OIG, which reviewed all MAO enrollees, noted that, “the lack of any other follow-up visits, procedures, tests, or supplies for these diagnoses…raises concerns that either: (1) the diagnoses are inaccurate and thus the payments are improper or (2) enrollees did not receive needed care for serious conditions reported only on HRAs or HRA-linked chart reviews.”^[9]  In this context, UnitedHealth Group benefited financially more than any other MAO, which raises serious questions about its practices.  The apparent fraud, waste, and abuse at issue is simply unacceptable and harms not only Medicare beneficiaries, but also the American taxpayer.  

For Congress and the American public to better understand UnitedHealth Group’s billing practices, please provide answers to the following questions no later than March 10, 2025:

1. What steps has UnitedHealth Group taken to review all diagnoses submitted to CMS for its Medicare Advantage enrollees (“enrollees”) that were identified only by HRAs or chart reviews (either manual or artificial intelligence) and to identify all submitted diagnoses that are obscure, irrelevant, or inaccurate?  Quantify the number and amount of inappropriate payments identified as a result of these actions.  Provide all records.^[10]

2. Provide all records that relate to the compliance program that UnitedHealth Group had in place from 2019-2024 to monitor the accuracy and appropriateness of the diagnosis codes submitted to CMS for enrollees, including the design and results of all audits conducted.

3. Provide all training manuals and guidance documents for conducting HRAs and manual chart reviews, a list of all software used during the course of an HRA and a manual chart review, and the logic rules for all electronic decision support tools embedded in the software.  Does UnitedHealth Group use artificial intelligence to conduct the aforementioned processes?  Are all diagnoses identified by artificial intelligence confirmed by a trained medical record reviewer?

4. Provide all policies and procedures for obtaining diagnostic confirmation from an enrollee’s primary care provider and ensuring the receipt of treatment for a new diagnosis identified by an HRA or a chart review.  Provide all documentation related to compliance audits of this process.

Thank you for your prompt review and response.  If you have any questions, please contact Tucker Akin with my Committee staff at (202) 224-5225.

Sincerely,

Charles E. Grassley

Chairman

Committee on the Judiciary