HealthIT Answers July 15, 2025
Introduction
The U.S. healthcare industry is once again in the spotlight—this time, with the scrutiny on UnitedHealth. The Department of Justice (DOJ) has launched a civil fraud investigation into UnitedHealth Group, which highlights the ethical challenges and complexities around risk adjustment in Medicare Advantage (MA). The increasing scrutiny has become a wake-up call for the industry, which has been walking a fine line between accurate coding and questionable practices that could compromise the integrity of the reimbursement system. The issue isn’t whether risk adjustment is necessary, but how far is too far, and at what cost?
What’s Under Scrutiny?
The DOJ is probing allegations of upcoding—adding unsupported or unnecessary diagnoses to inflate risk adjustment factor (RAF) scores and, by extension,...
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