President Trump and congressional Republicans often talk about cracking down on waste, fraud, and abuse in public benefits. On May 29, Massachusetts Attorney General Andrea Campbell, a Democrat, took a significant step to crack down on Medicaid fraud, filing a complaint in Suffolk Superior Court accusing health insurer United Healthcare of submitting more than $100 million in fraudulent claims to MassHealth.
The allegations, if proven, represent a huge breach of public trust by the insurer — and highlight one reason why many people are skeptical of both our country’s health care system and its social safety net.
As Campbell told reporters in a press call, when a company commits Medicaid fraud, “that erodes public trust in the institutions designed to help those in need.” And when people lose trust in health care, they’re less likely to seek the care they need.
A spokesperson for United Healthcare, in a statement emailed to the editorial board, called the complaint “meritless” and said it “doesn’t accurately describe our Senior Care Options program.”
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United Healthcare is Massachusetts’ largest provider of Senior Care Option plans, insurance plans for people over 65 who are eligible for both Medicare and Medicaid.
Under MassHealth requirements, members receive an in-home health assessment from an insurance company nurse, which is used to determine their health needs. The assessment is also used to put the member into a category, with Level 1 needing the lowest level of care and Level 3 needing the most care — typically someone who needs help with daily living and requires a skilled nursing aide multiple times a week. MassHealth pays the insurance company based on patients’ needs. In 2025, MassHealth paid $1,305 per month for an Eastern Massachusetts Level 1 member compared to $4,265 for a Level 3 member.
According to the allegations in the complaint, United Healthcare consistently told MassHealth that patients were sicker than they actually were to receive higher reimbursements.
▪ United allegedly labeled members Level 2, which includes patients with mental health and substance use disorders, by listing them as having conditions like depression or anxiety even though the members were never diagnosed with or treated for depression or anxiety.
▪ United allegedly said patients needed daily nursing services, classifying them as Level 3, with no evidence they needed those services. United allegedly said a member was given seven days a week of nursing services, when the member never received any. Some nurses said they were told to classify every patient over 79 and every patient who used an inhaler as Level 3.
▪ United’s own internal review allegedly found that in 2018-2019, patients were being incorrectly labeled as Level 3, but the insurer never told MassHealth it had overpaid.
The complaint alleges that the misrepresentations were “knowing and intentional.” United routinely understaffed its nurses, so nurses didn’t have enough time to do assessments. As a result, managers were told that nurses were copying and pasting clinical assessments from one patient for another patient or from a prior year for the current year. United allegedly created an incentive structure where nurses who labeled patients as more severe had fewer patients to assess. It allegedly abandoned quality control efforts that created backlogs.
Under state law, Massachusetts could receive treble damages — $300 million — if the allegations are proven in court.
To be sure, United Healthcare’s alleged conduct isn’t necessarily representative of all insurers. In addition to the state lawsuit, UnitedHealth Group (the parent company of United Healthcare) is also reportedly facing an investigation by the US Department of Justice into whether it reported inaccurate diagnoses to obtain higher Medicare payments. A 2024 investigation in STAT alleged that UnitedHealth pressured doctors to make patients seem sicker than they were to game the Medicare Advantage payment system. The company denies any misconduct.
In theory, the insurance industry can play a valuable role in health care by ensuring that people can afford medical care and patients get appropriate care they actually need. But the practice of upcoding — billing that makes patients look sicker than they are — only results in higher medical costs, which ultimately get passed on to all premium-payers. When allegedly bad actors like UnitedHealth try to cheat the system to inflate their profits, that undermines trust in insurers and in the health care system overall.
Editorials represent the views of the Boston Globe Editorial Board. Follow us @GlobeOpinion.