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UnitedHealthcare improperly classified many MassHealth members, overstating their health concerns to get higher reimbursements from the state, Campbell alleges.
Massachusetts Attorney General Andrea Campbell. Jessica Rinaldi / The Boston Globe, File
Massachusetts Attorney General Andrea Campbell sued the insurance giant UnitedHealthcare last week, alleging the company “systematically defrauded” the state’s Medicaid program out of at least $100 million.
The lawsuit centers on claims that United manipulated health assessments for older residents in order to get the state to pay out more money to the company. This was part of a wider “growth-at-all-costs strategy” that understaffed and overworked nurses while abandoning quality control in favor of profit, Campbell alleged.
“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,” Campbell said in a statement. “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.”
United denied Campbell’s allegations.
“The Massachusetts Attorney General’s complaint is meritless and doesn’t accurately describe our Senior Care Options program, which helps seniors with complex care meet their individual health needs. The Attorney General is simply wrong that Massachusetts seniors with complex care needs should not be receiving the support and services UnitedHealthcare is helping to provide. We remain focused on working with our state partner to help our members live healthier lives,” a spokesperson for the company said in a statement.
The alleged fraud occurred from 2015 through 2025 as MassHealth, the state’s Medicaid program, contracted with United to serve as a Senior Care Organization plan provider. United is paid certain rates per month per member enrolled in the program, and these rates are determined by United’s own assessments of each member’s health conditions.
The company is paid more for members with more serious health conditions. Members are assigned one of three levels of care, with Level 3 members resulting in the highest reimbursement rates, according to the lawsuit.
Level 2 classifications are reserved for members with behavioral health or substance use disorders. In submissions to MassHealth, United classified members as Level 2 by saying that they had diagnoses like depression and anxiety, even though these members “lacked any corresponding diagnosis or treatment associated with behavioral health or substantive use disorders,” according to the lawsuit.
For years, United improperly classified many members as Level 3, which is reserved for people with the most serious health conditions. In 2018 and 2019, United conducted a series of internal reviews and concluded that many Level 3 members had been improperly classified. The company then downgraded them to Levels 1 or 2, but reportedly never disclosed to MassHealth that it had been improperly paid at higher rates for these members before they were downgraded. United has also not repaid MassHealth for the “improperly inflated” payments, Campbell alleged.
Some Level 3 members were classified as such because they needed skilled nursing services daily or multiple times per week. But most of these members did not receive skilled nursing services at all in the week before United assessed their needs, and they did not actually require the nursing services that United said they did, according to the lawsuit. This allegedly resulted in improperly inflated payments to United.
United nurses responsible for making these member assessments repeatedly told their managers that evaluations “often included clinical assessments that were copied and pasted from prior evaluations of other patients,” according to the lawsuit. These included inaccurate diagnoses that did not reflect comprehensive reviews of each member’s health needs.
Campbell alleged that United “chronically understaffed” the nurses, creating an incentive structure where they “would not have to complete as many member assessments if they represented that the members had more serious health conditions, even if those members did not.”
United created a quality control team to focus on member assessments before they were submitted to MassHealth. But it “abandoned” the process for half of member assessments after a backlog threatened United’s bottom line, Campbell alleged.
Gov. Maura Healey’s budget proposal for fiscal year 2027 included $22.7 billion for MassHealth, a 7 percent net increase from the current fiscal year.
Total MassHealth spending is on track to have grown by $2.3 billion from fiscal year 2022 through fiscal year 2025. This recent spending growth has been driven by an increase in the cost per individual MassHealth member. Spending on long-term services and supports for older residents increased by 13 percent from 2024 to 2025 alone, according to state officials.
Ross Cristantiello
Ross Cristantiello, a general assignment news reporter for Boston.com since 2022, covers local politics, crime, the environment, and more.
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