The new Senate Judiciary Committee report describes how the insurer encouraged practices for recording high-risk diagnoses that lead to extra payments to its Medicare Advantage plans.
The Wall Street Journal, which has published a series of articles since 2024 spotlighting UnitedHealth’s billing practices, first reported the findings on Monday morning.
The probe was conducted at the request of Senate Judiciary Committee Chairman Sen. Chuck Grassley (R-Iowa) in part based on The Wall Street Journal investigation, which included articles on Medicare Advantage patients’ unusually high sickness or risk adjustment factors, billing Medicare for diseases that patients never had, and home visits conducted by nurses.
Medicare will pay insurers more money to care for sicker patients to cover the cost of treatment and to prevent payers from “cherry picking” healthier, less-costly patients to enroll in their plans. The agency calculates scores based on the information physicians provide about their patients’ specific health needs and insurers submit.
RELATED: WSJ investigation singles out UnitedHealth over high ‘sickness’ scores for MA patients
In a February 2025 letter to UnitedHealth, Grassley asked that the company provide all compliance program records in place from 2019-2024 about the monitoring of diagnoses codes submitted to the Centers for Medicare & Medicaid Services (CMS), training documents, policies and procedures, and the steps it takes to review all diagnosis it submits to CMS that were identifies only by in-home health risk assessments (HRA) or chart reviews (both manual and via artificial intelligence). UnitedHealth, the largest Medicare Advantage insurer in the United States, turned over 50,000 pages of records to the Senate Judiciary Committee.
The 105-page Senate report said that a review of the records provides evidence that shows UnitedHealth has “turned risk adjustment into a major profit centered strategy, which was not the original intent of the program." The organization has been able to maximize its risk adjustment scores by using “aggressive strategies to maximize these risk adjustment scores” and has been able to “leverage its size, degree of vertical integration, and data analytic capabilities to stay ahead of CMS’ efforts to counteract unnecessary spending related to coding intensity.”
Among the findings:
- The organization has used its robust diagnosis capture workforce and advanced data analytics capabilities to maximize its ability to capture diagnoses
- UnitedHealth has identified opportunities and strategies to increase its capture of untapped risk score garnering diagnoses
The report said Grassley’s staff will continue to evaluate the information, but the initial review reveals how UnitedHealth has been able to profit from the way that CMS calculates risk adjustment payments to Medicare Advantage organizations. The investigation, the report concludes, has shown that risk adjustment in Medicare Advantage has become a business in itself. Instead, Medicare Advantage organizations should receive payments based on the complexity and acuity of their members, not be knowing coding rules and finding new ways to expand inclusion criteria for diagnoses.”
RELATED: UnitedHealth Group is cooperating with the DOJ investigation into its Medicare billing practices
A UnitedHealth spokesman told The Wall Street Journal that it disagreed with the report findings and said it complies with Medicare requirements. “We remain focused on continuing to deliver lower costs, better access and higher quality care for the people we serve, including those in Medicare Advantage,” he told the publication.
Meanwhile, UnitedHealth is cooperating with the Department of Justice’s civil and criminal investigations over its practices within the Medicare program. In July, the company said it has full confidence in its practices and is committed to working cooperatively with the DOJ.
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