Senate report alleges Medicare upcoding by UnitedHealth

By John Hilton

A Senate report released Tuesday alleges that UnitedHealth Group is gaming the Medicare Advantage system to reap inflated payments.

The report from Sen. Chuck Grassley, R-Iowa, claims that UnitedHealth leverages its scale, data assets, and vertically integrated provider network to maximize Medicare Advantage risk adjustment payments. It is based on more than 50,000 pages of internal UHG documents.

Grassley, chairman of the Senate Judiciary Committee, said the insurer submitted more diagnoses and diagnosis codes than any other Medicare ‍Advantage organization. As a result, UHG received much higher government payments tied to the poor health of its patients, the report added.

"After a review of the records, this report provides evidence ⁠that shows UnitedHealth Group has turned risk adjustment into a major profit-centered strategy, which was not the original intent of the program," the report stated.

The report essentially repeats allegations that first surfaced last year in a report by the Wall Street Journal. UnitedHealth allegedly pressured nurses in its HouseCalls program to find and add more diagnoses to patient charts to boost their risk scores, the WSJ story said.

This led to inflated payments from Medicare Advantage, with a separate DOJ probe focusing on these same practices. The reports suggested UnitedHealth was gaming the system for billions in extra funds, prompting investor concerns and stock drops.

"We stand by the integrity of our Medicare Advantage program," UHG said in a May response to the WSJ story. A message seeking comment on the Grassley report was not returned.

Table showing with diagnoses were upcoded allegedly by United Health.

On a reform path

Since former CEO Stephen Hemsley returned to lead UHG in the spring of 2025, the insurer has implemented several changes designed to reform practices, all part of a plan to return to earnings profitability. Investors apparently like the direction UHG is heading, as shares are up nearly 13% in six months.

Other takeaways from the 105-page Senate report include:

• UHG has effectively turned risk adjustment into a profit-centered strategy, beyond its intended purpose.
• The company uses AI-enhanced data analytics, extensive chart reviews, in-home nurse assessments, and provider workflow control to capture more diagnoses than peers.
• UHG’s methods are replicated across the MA industry, because other MA organizations contract with UHG for coding insights and services.
• CMS attempts to curb “coding intensity” are not keeping pace with UHG’s ability to identify and exploit remaining diagnosis code opportunities.

InsuranceNewsNet Senior Editor John Hilton has covered business and other beats in more than 20 years of daily journalism. John may be reached at [email protected]. Follow him on Twitter @INNJohnH.