The mention of the lawsuit against United Healthcare (UHC) and what is alleged "up-coding" of claims to maximize reimbursement to the hospitals could reveal something very interesting that could affect the entire industry. When hospitals create medical records and bill insurance companies, most, if not all hospitals, use software by EPIC for that task. It should come as no surprise that EPIC has features built in to maximize the billing based on the patient encounter. For instance, EPIC's decision-support tools and alerts might suggest a higher-level code based on the complexity of care documented, which can lead to increased reimbursement rates.
What is maybe more interesting is that, outside of health insurance coverage directly through the government, employer sponsored insurance falls into two categories. The first is called fully-insured, or underwritten, where employers pay a premium and the insurance company, such as UHC takes on all the risk. The other is self-insured, where companies may pay a small administrative fee and then self-pay on each claim.
Where UHC could be in hot water is if their practices show that they let "up-coded" claims for self-insured customers fly through - after all, they aren't paying those bills - but then pushed back on hospitals for similar up-coded claims for their underwritten book of business because they were paying that bill. This is a massive loophole for abuse in the system and likely extends to Medicare Advantage plans, in which health insurance companies take on Medicare beneficiaries and are reimbursed by the government. Allowing up-coding of Medicare claims to fly through can massively increase their payments from the government over time.
I'm a bit surprised this hasn't been litigated in the past, but the entire system is so complex and there is so much opportunity for fraud, waste, and abuse that it's like playing whack-a-mole. That being said, it feels like the dam is cracking a bit.