United States v. United Healthcare Insurance Co.

The Centers for Medicare & Medicaid Services (CMS) pays Medicare Advantage organizations fixed monthly amounts for each enrollee. Medicare Advantage organizations have a financial incentive to exaggerate an enrollee’s health risks by reporting diagnosis codes unsupported by the enrollee’s medical records, and therefore, Medicare regulations require a Medicare Advantage organization to certify that the risk adjustment data is submits are accurate and truthful. Qui Tam Relator James Swoben filed a third amended complaint alleging that Medicare Advantage organizations performed biased retrospective medical record reviews, which rendered Defendants’ periodic certifications false, in violation of the False Claims Act. Defendants moved to dismiss Swoben’s claims. In response, Swoben sought to amend his complaint. The district court dismissed the third amended complaint with prejudice, concluding that Swoben failed to allege a claim with particularity as required by Fed. R. Civ. P. 9(b). The court also denied leave to amend, citing both futility of amendment and undue delay. The Ninth Circuit vacated the district court’s judgment, holding that the dismissing Swoben’s third amended complaint without leave to amend based on futility of amendment and undue delay and that leave to amend was proper in this case. View "United States v. United Healthcare Insurance Co." on Justia Law