Whistleblowers Accuse UnitedHealthcare/Optum of Medicare Fraud, Denying Critical Care to Nursing Home Patients

What You Should Know: 

– Less than a week after the resignation of UnitedHealth Group (UHG) CEO Andrew Witty, two whistleblowers have come forward with significant evidence alleging that Optum, a subsidiary of UnitedHealthcare (UHC), is engaged in dangerous and deceptive practices amounting to defrauding Medicare. 

– The accusations detail a purported “playbook” employed by UHC that systematically delays or outright denies critical care to vulnerable nursing home patients to reduce costs and maximize profits.

– Represented by Whistleblower Aid, the two former UHC nurse practitioners have submitted a comprehensive disclosure of these allegations to the Securities and Exchange Commission (SEC), the Federal Trade Commission (FTC), the Washington State Office of the Attorney General, and the U.S. Congress, demanding a thorough investigation. The disclosure claims the company intimidated and bullied medical providers into denying patients access to essential care.

The Alleged “Playbook”: Profits Over Patient Well-being in Nursing Homes

The whistleblowers describe a system where UHC allegedly implemented unconscionable cost-cutting measures, including the avoidance of even necessary hospitalizations for emergencies, to the detriment of vulnerable patients. According to the allegations, because off-site care and hospitalizations are more costly for the health insurer than care within a nursing facility, UHC designed its “playbook,” training materials, and rewards system to discourage such external care. This culture reportedly frames off-site care as a failure on the part of the provider, encouraging delays in critical care and refusal of hospitalizations, while rewarding providers who comply with these cost-saving measures, allegedly at the expense of patient well-being.

Disturbing Examples of Alleged Care Denial and Misleading Practices

The disclosure includes disturbing specific examples of care allegedly denied or delayed in nursing homes. In one instance, a patient vomiting fecal-like matter was reportedly denied hospitalization by UHC. Despite a nurse suspecting potentially fatal gastrointestinal bleeding, the concerns of both the nurse and the patient were allegedly ignored by UHC.

Another case detailed involves a UHC phone operator, who was off-site and had no direct contact with the patient, allegedly misdiagnosing a man experiencing a stroke. Though the hospital was only five minutes away, the patient was not admitted for over an hour due to adherence to UHC’s playbook, resulting in permanent neurological damage, including slurred speech.

Furthermore, the whistleblowers claim that UHC materials mandate caregivers to pressure elderly patients into signing “Do Not Resuscitate” (DNR) orders. This was allegedly done by misleading patients into believing their conditions were worse than they were, including suggesting imminent death, in an effort to use these DNR orders to keep patients out of hospitals and minimize costs for UHC.

“Up-Coding” Scheme and Retaliation Against Providers Alleged

Beyond care denial, Whistleblower Aid clients also reportedly witnessed an “up-coding” scheme dictated by UHC training. This scheme allegedly required managers and staff to exaggerate patient conditions to falsely claim more substantial reimbursements from Medicare Advantage.

The whistleblowers also assert that when they prioritized patient safety and did hospitalize a patient to save their life, UHC docked their compensation. This was allegedly followed by a “grueling, manager-led, retrospective review” aimed at blaming the caregiver for the patient’s change in condition, further pressuring caregivers into complying with the UHC/Optum playbook.

A Call for Accountability

One of the whistleblowers, Dr. Maxwell Ollivant, a nurse practitioner formerly employed by UHC, stated, “Scores of elderly patients never received the care that they needed, all because UnitedHealthcare skimped on care to cut costs. UnitedHealthcare is compelling medical professionals to comply with its financially-driven playbook at the expense of patient safety, forcing providers to violate their ethical obligations. I’d like to see them held accountable for putting profits over patients”.