UnitedHealth under criminal probe for possible Medicare fraud: WSJ

px_eliezer_ · 2025-05-15T12:33:14+00:00

The U.S. Department of Justice is carrying out a criminal investigation into UnitedHealth Group for possible Medicare fraud, the Wall Street Journal reported on Wednesday…. On Tuesday, UnitedHealth Group’s CEO, Andrew Witty, stepped down unexpectedly, and the company simultaneously suspended its 2025 financial forecast due to rising medical costs…. https://www.reuters.com/business/healthcare-pharmaceuticals/unitedhealth-under-criminal-probe-possible-medicare-fraud-wsj-reports-2025-05-14/ The Feds reimburse Medicare Advantage programs based on how how sick the patients are (for example, all the diagnosis codes that apply to each patient), rather than a flat rate per person. Thus there can be disagreements, as the two sides have different motivations. United is the same company that brought us the Change Healthcare hacking, the massive multi-tentacled company Optum, and so forth.

Splitpair

HooRU Honestly, I don’t understand why only America refuses public health care when nearly every other country of economic strength, often less than our’s, can do it. All that insurance companies are is money grabs.

Because most of us prefer having choices versus being told what we shall accept and when we can accept it.

Somewhat-Reticent

HooRU We are buffoons being suckered.

Or our legislators use Deliberate Ignorance and hide compromise with cartels?
The door was opened with “Medicare Advantage”.

px_eliezer_

Splitpair We switched to United after my primary refused to accept Humana as they where refusing to pay claims or greatly discounted claims her office filed, requiring her claims adjuster to resubmit claims over and over until Humana finally paid what the rightfully owed.

THIS is what bugs doctors more about insurance plans in general—not the payment levels, but the hassle factor.

Humana had a big drop in their Medicare ratings.

Having lost one lawsuit about it, Humana has now filed another lawsuit.
https://www.healthcarefinancenews.com/news/humana-sues-cms-once-more-over-medicare-advantage-star-ratings

InternetJeff

Somewhat-Reticent The door was opened with “Medicare Advantage”.

My parents had Medicare Advantage and loved it. The only alternative for them was original Medicare, and prior to moving to Advantage they were not happy with original Medicare. I remember my Dad commenting that he got money back under Medicare Advantage, but I don’t remember the details. I think the bottom line is that it is good for people to have choices.

px_eliezer_

InternetJeff

I’m on a Medicare Advantage plan myself, everything has pros and cons.

The Medicare Advantage plans were supposed to save money for the Medicare program overall, but (especially considering how they are subsidized) it’s not been a success in that regard.

Changes will be ahead (and this is REGARDLESS of which administration is in control).

The head of CMS (Medicare/Medicaid) now is Dr Mehmet Oz (really) and it WILL take a wizard to fix things.

InternetJeff

px_eliezer_ I’m on a Medicare Advantage plan myself

Do you get “money back”? I may be wrong, but I think they were/are called premium rebates or something similar.

px_eliezer_

InternetJeff Do you get “money back”? I may be wrong, but I think they were/are called premium rebates or something similar.

Depends on the plan, and even from the same company it can vary widely—as an example Aetna may have 10-12 plans in an area.

Some Medicare Advantage plans [charge] a premium on top of the regular Medicare premium.
Some plans [do NOT charge] a premium on top of the regular Medicare premium.
Some plans [actually give a rebate], typically used to be 50/month but now is maybe 40/month.

But it is SO complicated with co-pays, deductibles, drug benefits, optical, dental, and so forth.

Getting money back may OR may not be a good deal when considering all other factors.

robxr4ti

Astyanax oh I’m sure he’ll be viewed as a hero in the media because “Big healthcare = bad”. We’ll hear from the same people who tried to justify the murder in the first place.

robxr4ti

ThirdShifter and that didn’t take long at all…

ElQuintron

Split and locked OT discussion about Canadian Healthcare

Splitpair

InternetJeff A Toronto-based research team met with and surveyed some 10,000 Canadians about the state of the health-care system — and what they found is deep dissatisfaction and frustration with primary care as the country grapples with a severe shortage of family doctors.

When caps are placed on the payments of health care procedures to the providers it is a no brainer as to why health care providers will not open practices and instead seek out other means of getting paid for what their knowledge is worth.

HooRU

My advantage plan does have an allotment for “money”, or rather, a monthly amount that can be used for OTC meds or other limited things. It’s 100 and I use it to get OTC or to pay the electric bill (since I used a CPAP). My electric bill is almost 300 in the summer now with 2 window units.

the plan pays LESS for visits and treatments in most cases, in fact much less. But I’m on a dual plan with Medicaid. In another year that is expected to change, but as I am 67, I may be exempt. I won’t go into every detail, but it does offer some coverage for dental that I needed.

In my opinion, for most, advantage is not an advantage and is a risky choice.

This is the only well to do nation where someone can find fananical ruin from being sick and die not getting treatment.

Splitpair

px_eliezer_ THIS is what bugs doctors more about insurance plans in general—not the payment levels, but the hassle factor.

My primary has one person in the office who’s full time job is filing insurance claims, I spoke with her about Humana and was advised if she files a claim with Humana and the procedure codes are not in the order Humana will accept the entire claim is denied.

A example would be, I have an infection in my hand from a spider sting, I receive a consultation with my doctor, a shot of antibiotics and a script for backup antibiotics to be taken over the next two weeks.

If she by accident enters the codes for the shot, a consultation and the backup antibiotics in that order the claim is instantly denied.

Humana does everything possible to deny claims, which is why my primary will no longer work with them forcing us to find a new health care insurance plan.

Her claims person recommended we look into United as they don’t play games, they just pay for services we are subscribed to.

Dks01

robxr4ti Speak untruth, expect correction. With facts.

Dks01

HooRU This is the only well to do nation where someone can find fananical ruin from being sick and die not getting treatment.

Sadly, all too true.

px_eliezer_

Splitpair Humana does everything possible to deny claims, which is why my primary will no longer work with them forcing us to find a new health care insurance plan.

Her claims person recommended we look into United as they don’t play games, they just pay for services we are subscribed to.

JAKE
Matt. How you doing?
MATT
Hi Elwood. How ya doing? How was Joliet.
JAKE
Oh it was bad. Thursday night they’d serve
a wicked pepper steak.
MATT
Can’t be as bad as the cabbage roll at the
Terre Haute Federal Penn.
ELWOOD
Or that oatmeal at the Cook County slammer.
MATT
Yeah they all pretty bad.

Blues Brothers.

robxr4ti

Dks01 what “untruth” was spoken? I’m confused.

dave

Splitpair Because most of us prefer having choices versus being told what we shall accept and when we can accept it.

Except that with US medical insurance, the insurer decides whether you can have the treatment your doctor considers medically necessary.

I suppose you have the choice to pay out of pocket. After having paid the premium for the insurance that does not cover you. Sure you have the choice of insurance companies, but that doesn’t guarantee the particular treatment will be covered, when the time comes.

The choice, for those who are not self-funded, is therefore only a choice of gatekeepers.

Splitpair

dave Except that with US medical insurance, the insurer decides whether you can have the treatment your doctor considers medically necessary.

Not true at all, I can have any procedure I need and United will cover it.

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