Massachusetts Attorney General Andrea Joy Campbell has sued UnitedHealthcare for allegedly misrepresenting members’ health conditions to defraud the state.
The insurer is accused of inflating patient care levels in its MassHealth Senior Care Options plan to wrongfully secure larger payments.
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The lawsuit filed in Suffolk Superior Court says MassHealth, Massachusetts’ Medicaid programme, was overcharged by at least $100m.
The Senior Care Options programme covers eligible people aged 65 and above in designated areas of the state.
Each enrolee must undergo a full in-home clinical review so their condition can be placed into one of three care bands. Level 1 carries the lowest payment rate and Level 3 the highest.
UnitedHealthcare is the biggest provider of these plans in Massachusetts.
Campbell said: “The state’s managed care plans need to act in good faith on behalf of their members and the financial resources of our state’s Medicaid programme. Our investigation found that United Healthcare knowingly violated these obligations by manipulating health assessments to increase its profits.
“This lawsuit sends a clear message that no company is above the law, and my office will hold companies accountable for exploiting vulnerable residents and misusing taxpayer dollars.”
The Attorney General’s Office says the alleged conduct took place in three main ways.
One allegation concerns members placed in Level 2, a category intended for people with behavioural health or substance use disorders.
According to the complaint, UnitedHealthcare reported conditions such as depression or anxiety to MassHealth even where members did not have matching diagnoses or treatment linked to behavioural health or substance use disorders.
A second allegation relates to members assigned to Level 3, which is intended for the most serious cases. The complaint says many people were assessed as meeting that threshold even though they were not eligible for Level 3 services.
It also says that, from 2018 into 2019, internal reviews at UnitedHealthcare found that a significant number of Level 3 classifications were incorrect.
The state alleges that UnitedHealthcare did not inform MassHealth that it had received higher payments for those members before their status was lowered, and did not return any of the extra money linked to those classifications.
The third allegation centres on claims that certain members required daily skilled nursing services.
The Attorney General’s Office says most of those members neither needed nor received such care, yet the submissions resulted in higher payments from MassHealth.
The state further alleges that these actions were deliberate and stemmed from a “growth at all costs” strategy that encouraged field nurses to record members as being in worse condition or less independent than they were.
UnitedHealth Group reported net earnings of $6.48bn for the first quarter of 2026, compared with $6.47bn in the same period a year earlier.
