Massachusetts Sues United Healthcare For Defrauding MassHealth Out Of $ 100 Million

Massachusetts Attorney General Andrea Joy Campbell sued United Healthcare on May 29th, alleging the company has defrauded MassHealth by making senior citizens in its Senior Care Options (SCO) plan appear sicker than they were to secure higher payments.  Senior Care Options (SCO) combines MassHealth and Medicare benefits into one plan with one card and care team for individuals aged 65 and above:

https://www.mass.gov/news/ag-campbell-sues-united-healthcare-for-defrauding-masshealth-out-of-100-million

AG Campbell Sues United Healthcare for Defrauding MassHealth Out of $100 Million
Lawsuit Alleges that United Manipulated and Misrepresented Member Health Statuses to Obtain Higher Payments from MassHealth
Office of the Attorney General for immediate release - May 29, 2026

BOSTON — Massachusetts Attorney General Andrea Joy Campbell today filed a lawsuit in Suffolk Superior Court against UnitedHealthcare Insurance Company, d/b/a UnitedHealthcare Community Plans of Massachusetts (United), alleging the company falsely manipulated the health status of MassHealth members enrolled in its Senior Care Options (SCO) plan to secure higher payments from the Commonwealth. The complaint estimates that the scheme defrauded MassHealth, the state’s Medicaid program, of at least $100 million.

“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 program. Our investigation found that United Healthcare knowingly violated these obligations by manipulating health assessments to increase its profits,” said AG Campbell. “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.”

MassHealth’s SCO program serves eligible members age 65 or older living in designated service areas across Massachusetts. Enrollees must receive a comprehensive in-home clinical assessment to determine the member’s health status and assign them one of three levels of care, ranging from least serious and lowest payment rate (Level 1) to most serious and highest payment rate (Level 3). United is the largest provider of SCO plans in Massachusetts.

The Attorney General’s Office (AGO) alleges that United manipulated the health statuses of its members to increase profits in three principal ways. First, United submitted assessments of members in the United SCO Plan that led to their classification as Level 2, which is reserved for members with behavioral health or substance use disorders. United classified members by identifying, in its submissions to MassHealth, that members had diagnoses like depression or anxiety, even though those members lacked any corresponding diagnosis or treatment associated with behavioral health or substantive use disorders.

Second, the AGO further alleges that United improperly assessed many members in the United SCO Plan with health conditions satisfying Level 3, reserved for members with the most serious health conditions, even though those members did not qualify for Level 3 services. Beginning in 2018 and continuing into 2019, United became aware through a series of internal reviews that many of its members at Level 3 had been improperly classified. United never disclosed to MassHealth that it had been improperly paid at higher rates for these members prior to their being downgraded, nor has it repaid MassHealth for any of the improperly inflated payments United received while the members were incorrectly classified at Level 3.

Third, United submitted assessments to MassHealth for members in the United SCO Plan that represented that those members needed daily skilled nursing services. Despite these representations, most of those members did not need or receive daily skilled nursing services. As a result, United received higher payments from MassHealth for these members than it should have.

The AGO alleges that these were intentional failures, the result of a “growth at all costs” strategy employed by United that incentivized and encouraged its field nurses to code MassHealth members as sicker or less able than they were.

This matter is being handled by Assistant Attorneys General Kevin O’Keefe and Mary-Ellen Kennedy, Senior Data Scientist William Welsh, Senior Healthcare Fraud Investigator Christine Barker, and Investigator Rachel Wiesler, all of the AGO’s Medicaid Fraud Division. MassHealth provided substantial assistance with the investigation.

The AGO’s Medicaid Fraud Division is a Medicaid Fraud Control Unit, annually certified by the U.S. Department of Health and Human Services to investigate and prosecute health care providers who defraud the state’s Medicaid program, MassHealth. The Medicaid Fraud Division also has jurisdiction to investigate and prosecute complaints of abuse, neglect and financial exploitation of residents in long-term care facilities and of Medicaid patients in any health care setting. Individuals may file a MassHealth fraud complaint or report cases of abuse or neglect of Medicaid patients or long-term care residents by visiting the AGO’s website.

The Massachusetts Medicaid Fraud Division receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $6,458,176 for federal fiscal year 2026. The remaining 25 percent, totaling $2,152,724 for FY 2026, is funded by the Commonwealth of Massachusetts.