A US Senate Judiciary Committee investigation has alleged that UnitedHealth Group adopted aggressive strategies to secure payments-boosting diagnoses for its Medicare Advantage members, reported the Wall Street Journal (WSJ).  

The findings stem from the committee’s review of 50,000 pages of internal company documents supplied by UnitedHealth last year. 

Within the Medicare Advantage system, the federal government provides insurers with a lump sum to manage health benefits for older and disabled Americans. 

Additional payments are offered for enrollees with certain costly diagnoses under the risk adjustment process.  

The committee’s report concluded that UnitedHealth “turned risk adjustment into a business, which was not the original intent”. 

The probe was initiated by Senator Chuck Grassley, chair of the committee, following a WSJ investigation published in 2024.  

The WSJ reporting highlighted how UnitedHealth frequently added diagnoses to patient files, generating billions of dollars in extra government payments. 

In some instances, these entries were described as “questionable” or incorrect, and there was little evidence that patients received treatment for the listed conditions. 

UnitedHealth is currently under multiple investigations including both civil and criminal inquiries by the US Department of Justice, which the company disclosed in July.  

A spokesperson for UnitedHealth disagreed with the Senate committee’s characterisations and said the company adheres to Medicare regulations and has performed well in audits of diagnoses. 

He said: “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.” 

UnitedHealth has stated it is cooperating with the probes. 

The company also dismissed some media accounts as “incomplete and inaccurate” but did not specify particular inaccuracies. 

The Senate report does not allege legal wrongdoing or make formal recommendations.  

However, it outlines how UnitedHealth deployed various methods such as sending nurses to patients’ homes to collect additional diagnoses, incentivising doctors with bonuses for considering new diagnoses and using AI alongside data mining techniques to scan medical records for unreported conditions.  

The report stated UnitedHealth “appears to use all of these mechanisms to the utmost degree”. 

Among the reviewed documents were training manuals and guidelines that sometimes directed staff to diagnose payment-triggering conditions without standard confirmatory tests. 

According to the report, staff were taught to diagnose atrial fibrillation based on certain medications rather than electrocardiogram results.  

For chronic obstructive pulmonary disease, while guidelines referenced lung function testing for confirmation, providers were advised to code the diagnosis even when such tests had not been performed. 

The report also notes that for patients prescribed opioids for pain relief, staff were instructed to diagnose opioid dependence regardless of whether there was any evidence of misuse, resulting in higher payments.  

When opioid therapy stopped, employees were told to continue using an “opioid dependence in remission” diagnosis. 

The committee did not assess whether UnitedHealth’s diagnostic guidance was medically appropriate but pointed to prior WSJ reporting on cases where diabetic cataracts were coded after patients had already undergone cataract removal surgery.  

Some medical professionals have called such practices “anatomically impossible”.  

The Senate report states that UnitedHealth “later reversed course”.  

Nurse practitioners within UnitedHealth’s HouseCalls programme were at one point directed to use a device called QuantaFlo to test for peripheral artery disease during home visits, according to internal documents cited by the committee.  

Some clinicians previously told the WSJ that this device often produced false positives.  

As per the report, UnitedHealth received $1.4bn between 2019 and 2021 from diagnoses made during these visits.  

The company has since stopped using QuantaFlo following changes in Medicare payment rules. 

UnitedHealth stated that it revised its home screening methods last year after Medicare removed several diagnosis-based extra payments.  

The company disclosed that these regulatory changes contributed to weaker financial results last spring and a subsequent decline in its share price. 

UnitedHealth asserts that its HouseCalls initiative contributed to fewer hospitalisations and emergency visits among seniors and says it has quality controls intended to ensure diagnosis accuracy.