Massachusetts attorney general's lawsuit alleges $100M fraud by UnitedHealthcare

The attorney general in Massachusetts is suing UnitedHealthcare, alleging in the lawsuit that the Minnetonka-based health insurance giant pocketed millions by overstating the health risks of lower-income residents enrolled in a health plan for Medicaid beneficiaries.

Between January 2015 and December 2025, UnitedHealthcare systematically defrauded the state's MassHealth program by misclassifying patients, improperly assessing their conditions and wrongly representing their need for skilled nursing care, according to the lawsuit filed May 29 by Attorney General Andrea Joy Campbell.

UnitedHealthcare called the allegations untrue. But the Massachusetts attorney general alleges the misrepresentations resulted in the health insurer receiving and retaining more than $100 million in fraudulent payments.

Massachusetts expected the company to act in good faith on behalf of low-income Medicaid beneficiaries and the financial resources of the state's program, Campbell said in a statement.

"Our investigation found that UnitedHealthcare knowingly violated these obligations by manipulating health assessments to increase its profits," she said.

UnitedHealthcare called the allegations meritless and said the lawsuit doesn't accurately describe the company's Senior Care Options program, which is open to patients who get Medicaid and Medicare.

Massachusetts seniors with complex health care needs should be getting all services UnitedHealthcare is helping to provide, the company said in a statement.

"The Attorney General is simply wrong," UnitedHealthcare said. "We remain focused on working with our state partner to help our members live healthier lives."

UnitedHealthcare, which is the nation's largest health insurer, is the massive health benefits business run by Eden Prairie-based UnitedHealth Group.

Over the years, UnitedHealth Group has faced allegations of boosting patient risk scores in Medicare Advantage plans to increase government reimbursements -- a charge the company has fervently denied. Medicare is the insurance program generally used by Americans 65 and older. It pays private Advantage insurers more to manage medically complex patients, creating an incentive for insurers to make patients look as sick as possible on paper.

Concerns about overly aggressive diagnosis coding have been less common in Medicaid, the state-federal program where UnitedHealthcare was providing coverage to more than 7 million people across the country as of the end of March. More than 30 states hire the insurer to manage care for Medicaid beneficiaries.

MassHealth is the name for Massachusetts' Medicaid program, which provides coverage for lower-income residents.

The lawsuit says UnitedHealthcare contracted with MassHealth to be a Senior Care Organization (SCO), which developed and administered a health care program for seniors age 65 and older.

MassHealth paid UnitedHealthcare a set fee per enrollee per month, based on assessments of those members' health conditions. Like Medicare, the Medicaid program paid higher fees for beneficiaries that United represented as having more serious health problems, the lawsuit said.

In Eastern Massachusetts during 2025, for example, MassHealth paid $1,305.57 per month for a member with "Level 1 care needs versus $4,265.49 per month for a beneficiary with higher "Level 3 needs.

"If MassHealth had known that a member was assigned an improper level based on an untruthful or inaccurate assessment, MassHealth would not have made the ... payment at the rate," the lawsuit said.

United's fraud on the program was knowing and intentional, according to the lawsuit, including untimely clinical assessments and inaccurate diagnoses.

The company chronically understaffed nurses who were responsible for assessments, the lawsuit said, and created an incentive structure where "overworked nurses would not have to complete as many member assessments if they represented that the members had more serious health conditions."

"United relentlessly pursued a growth-at-all-costs strategy that failed to allocate resources to ensure that it accurately reported members' conditions," said the lawsuit filed in Suffolk County's superior court.

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