By Tiffany Williams –
BOSTON — Massachusetts Attorney General Andrea Joy Campbell has filed a lawsuit against UnitedHealthcare Insurance Company, doing business as UnitedHealthcare Community Plans of Massachusetts, alleging the company improperly manipulated the health status classifications of MassHealth members enrolled in its Senior Care Options program to secure higher payments from the Commonwealth.
The lawsuit, filed in Suffolk Superior Court, alleges that the company’s actions defrauded MassHealth, the state’s Medicaid program, of at least $100 million. According to the Attorney General’s Office, UnitedHealthcare knowingly submitted inaccurate health assessments that resulted in higher reimbursement rates from the state for members enrolled in its Senior Care Options, or SCO, plan.
“The state’s managed care plans need to act in good faith on behalf of their members and the financial resources of our state’s Medicaid program. Our investigation found that United Healthcare knowingly violated these obligations by manipulating health assessments to increase its profits,” said AG Campbell. “This lawsuit sends a clear message that no company is above the law, and my office will hold companies accountable for exploiting vulnerable residents and misusing taxpayer dollars.”
MassHealth’s Senior Care Options program serves eligible residents age 65 and older who live in designated service areas throughout Massachusetts. Program participants receive comprehensive in-home clinical assessments that determine their health status and place them into one of three levels of care. Those classifications range from Level 1, representing the least serious conditions and lowest payment rates, to Level 3, which is reserved for members with the most significant health needs and highest reimbursement levels.
UnitedHealthcare is the largest provider of Senior Care Options plans in Massachusetts.
According to the complaint, the Attorney General’s Office alleges that UnitedHealthcare increased its profits by manipulating member classifications in three primary ways.
The lawsuit alleges that the company submitted assessments that classified members as Level 2 based on behavioral health or substance use disorders, even when those members lacked corresponding diagnoses or treatment related to behavioral health or substance use conditions. The complaint states that diagnoses such as depression or anxiety were identified in submissions to MassHealth despite the absence of supporting treatment or diagnosis records that would qualify those members for the higher level of care.
The Attorney General’s Office further alleges that UnitedHealthcare improperly classified many members as Level 3, a designation reserved for individuals with the most serious health conditions. According to the complaint, internal reviews conducted by the company beginning in 2018 and continuing into 2019 revealed that numerous members had been incorrectly classified at the highest level of care.
The lawsuit alleges that despite becoming aware of those findings, UnitedHealthcare did not disclose the improper classifications to MassHealth and did not repay funds it received through the higher reimbursement rates while those members remained classified at Level 3.
The complaint also alleges that UnitedHealthcare submitted assessments indicating certain members required daily skilled nursing services. According to the Attorney General’s Office, many of those members neither required nor received daily skilled nursing care, resulting in the company receiving higher payments from MassHealth than it was entitled to receive.
The Attorney General’s Office alleges the actions were not isolated mistakes but part of an intentional strategy designed to increase revenue. According to the lawsuit, the company employed a “growth at all costs” approach that incentivized and encouraged field nurses to classify MassHealth members as having more severe health conditions or greater functional limitations than they actually possessed.
The case is being handled by Assistant Attorneys General Kevin O’Keefe and Mary-Ellen Kennedy, Senior Data Scientist William Welsh, Senior Healthcare Fraud Investigator Christine Barker, and Investigator Rachel Wiesler, all of the Attorney General’s Medicaid Fraud Division. The Attorney General’s Office said MassHealth provided substantial assistance during the investigation.
The Medicaid Fraud Division serves as Massachusetts’ Medicaid Fraud Control Unit and is certified annually by the U.S. Department of Health and Human Services. The division is responsible for investigating and prosecuting healthcare providers accused of defrauding MassHealth, as well as investigating allegations of abuse, neglect, and financial exploitation involving long-term care residents and Medicaid patients in healthcare settings.
According to the Attorney General’s Office, the Massachusetts Medicaid Fraud Division receives 75 percent of its funding from the U.S. Department of Health and Human Services through a federal grant totaling $6,458,176 for federal fiscal year 2026. The remaining 25 percent, totaling $2,152,724, is funded by the Commonwealth of Massachusetts.
The allegations outlined in the lawsuit remain claims filed by the Attorney General’s Office. The case will proceed through Suffolk Superior Court, where the allegations will be subject to judicial review and litigation.