Centers for Medicare & Medicaid Services

Centers for Medicare & Medicaid Services

UnitedHealth Confirms DOJ Criminal and Civil Investigation for Medicare Advantage Upcoding Fraud

| Importance: 9/10

On July 24, 2025, UnitedHealth Group confirmed in an SEC filing that the Department of Justice has launched both criminal and civil investigations into the company’s Medicare Advantage billing practices, focusing on systematic upcoding fraud that may have generated billions in government …

UnitedHealth Group UnitedHealthcare Department of Justice Centers for Medicare & Medicaid Services healthcare medicare-advantage insurance-fraud regulatory-capture systematic-corruption
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HHS Watchdog Finds Health Risk Assessments Drove $7.5 Billion in Medicare Advantage Overpayments Without Additional Patient Care

| Importance: 9/10

On October 31, 2024, the Department of Health and Human Services Office of Inspector General (OIG) released a report estimating that Medicare Advantage insurers received at least $7.5 billion in improper payments in 2023 from Health Risk Assessments (HRAs) that added diagnoses to inflate risk scores …

Department of Health and Human Services Office of Inspector General Centers for Medicare & Medicaid Services Medicare Advantage insurers healthcare medicare-advantage insurance-fraud systematic-corruption regulatory-capture
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Humana Pays $90 Million to Settle First-of-Its-Kind Medicare Part D Fraud Case for Fraudulent Bidding

| Importance: 8/10

On August 16, 2024, Humana agreed to pay $90 million to settle the first whistleblower lawsuit alleging systematic fraud in Medicare Part D prescription drug program bidding. The case exposed how Humana maintained “two sets of books”—submitting false financial projections to the Centers …

Humana Centers for Medicare & Medicaid Services Department of Justice Steven Scott (whistleblower) healthcare medicare-advantage insurance-fraud systematic-corruption whistleblower
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