The US Department of Justice is asking a California federal court to reject a special master’s report and recommendations to grant summary judgment to UnitedHealth Group in a case involving allegations that the company improperly obtained billions from the Medicare Advantage program.
The DOJ became involved in the case in 2017, intervening on behalf of a former UnitedHealth finance director who claimed the company used inaccurate diagnosis codes to inflate Medicare payments.
The department argued that UnitedHealth employed teams of medical coders to identify diagnosis codes that would lead to higher payments, resulting in $7.2 billion collected from Medicare. However, when miscoded diagnoses were found, the company did not correct them. DOJ claims the company kept $2.1 billion in payments it was not entitled to by failing to address 1.97 million unsupported diagnosis codes.
In its motion to review the special master’s findings, the DOJ argued the conclusions were flawed because the special master incorrectly determined the government did not provide sufficient evidence the codes were unsupported. The DOJ maintains it presented reviews from its own coders, who have accuracy rates of 95% or higher.
The case traces back to 2011, when whistleblower James Swoben filed a lawsuit accusing UnitedHealth of submitting false diagnoses to increase Medicare payments.
The DOJ’s complaint, filed in 2017, alleged the company disregarded medical information, leading to overpayments. The DOJ also claimed UnitedHealth used chart reviews conducted by HealthCare Partners to identify additional diagnoses for higher payments but ignored codes that could reduce payments.
In 2017, a district judge dismissed the DOJ’s claims, finding they did not meet necessary legal standards. However, in March 2025, a court-appointed special master recommended the case proceed to trial, stating that the DOJ’s evidence lacked substance.
The DOJ is now seeking to have this recommendation overturned, asserting that failure to address potential overpayments constitutes improper avoidance of payment obligations to the government, even without proof of fraud.
Meanwhile, UnitedHealth denies the allegations, asserting its practices comply with Medicare regulations. The company is also facing a class-action lawsuit in Minnesota, over allegations it uses artificial intelligence to deny Medicare Advantage claims without physician input.
