Overview
- The state Attorney General filed a civil complaint in Suffolk Superior Court accusing UnitedHealthcare of inflating in‑home clinical assessments in the Senior Care Options program to trigger higher MassHealth payments.
- Massachusetts says the alleged scheme included mislabeling behavioral‑health diagnoses to qualify members for higher payment bands and assigning many people to the highest‑paying Level 3 without meeting that level’s clinical criteria.
- The complaint also alleges UnitedHealthcare reported daily skilled nursing visits that most members did not need or receive, which increased per‑member reimbursements.
- State filings and reporting cite internal UnitedHealthcare reviews from 2018–2019 that found widespread incorrect Level 3 classifications and say the company revised assessments without disclosing downgrades or repaying excess funds.
- The state seeks civil penalties, treble damages, interest and repayment of overpayments, and the case could affect oversight of managed‑care contractors and services received by older and dual‑eligible MassHealth beneficiaries.