You Should Know...
Lessons From United's Court "Win"
The compliance world is buzzing about the partial dismissal by a Federal judge of the qui tam action United States ex rel. Benjamin Poehling v. Unitedhealth Group, Inc et al.
Here's what you need to know.
The massive, multibillion-dollar case hinged on two key allegations; the defendant knowingly submitted false risk-codes and did not return money for previously submitted risk codes they knew to be false.
It's an enormous case with enormous implications.
It will set the tone for risk code enforcement for the next decade.
The judge dismissed the claims associated with the first set of allegations, though the door for an amended complaint was left open.
The action associated with the second was allowed to proceed. It's still a 9-to-10 figure claim.
If you're going to audit your risk-code submissions, then return the money you identify as inaccurately paid.
By statute, you only have a few weeks to do so.
This might seem self-evident, but if someone like United allegedly isn't doing so many other organizations probably aren't either.
So make sure your workflows include follow-through---all the way to returning any inappropriate payments.
In this case, the result of not doing so might be an enormous clawback and potential criminal charges.
All because one employee figured out what was going on, gathered evidence and obtained representation.
For a large insurer, such compliance actions may simply be considered the cost of doing business.
For someone even a little bit smaller, they might change your life---and very much for the worst