Campbell sues – Massachusetts Attorney General Andrea Campbell filed a lawsuit accusing UnitedHealthcare of “systematically” defrauding MassHealth of at least $100 million by improperly classifying seniors’ care needs to drive higher payments—claims the insurer denies.
For years. the MassHealth program has depended on careful medical assessments to decide how much it pays for each enrollee’s care. In her lawsuit. Massachusetts Attorney General Andrea Campbell says UnitedHealthcare treated those assessments like a lever—tightening them just enough to pull more money from the state.
Campbell sued UnitedHealthcare last week, alleging the company “systematically defrauded” the state’s Medicaid program out of at least $100 million. Her complaint alleges United manipulated health assessments for older residents after MassHealth contracted with United for its Senior Care Organization plan provider services.
“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 the allegations. In a statement. a company spokesperson said the complaint is “meritless” and “doesn’t accurately describe our Senior Care Options program.” The spokesperson said the Attorney General is wrong that Massachusetts seniors with complex care needs should not be receiving the support and services UnitedHealthcare is helping to provide. adding that the company remains focused on working with its state partner to help its members live healthier lives.
At the center of the dispute is how United is paid. Under the MassHealth contract for Senior Care Organization plan provider services, United receives certain monthly rates for each member enrolled. The rates are set by United’s own assessments of each member’s health conditions. The lawsuit says United earns more when members are assessed as having more serious health problems.
Members are assigned one of three levels of care. The highest reimbursement rates go to Level 3 members, according to the lawsuit. Level 2 classifications are reserved for members with behavioral health or substance use disorders.
Campbell’s complaint alleges United submitted classifications that overstated members’ needs. It says United classified members as Level 2 by pointing to diagnoses such as depression and anxiety. even though those members “lacked any corresponding diagnosis or treatment associated with behavioral health or substantive use disorders. ” according to the lawsuit.
The lawsuit also accuses United of improperly classifying many members as Level 3. Level 3 is reserved for people with the most serious health conditions. Campbell alleges this is where the payments were inflated.
The complaint says that in 2018 and 2019, United conducted internal reviews and concluded that many Level 3 members were improperly classified. It then downgraded them to Levels 1 or 2, the lawsuit says. But Campbell alleges United reportedly never disclosed to MassHealth that it had been improperly paid at higher rates for those members before the downgrade. and she says United has not repaid MassHealth for the “improperly inflated” payments.
In explaining how the Level 3 labels were justified. Campbell’s complaint distinguishes between what some members were said to need and what. she alleges. they actually received. Some Level 3 members were classified as such because they needed skilled nursing services daily or multiple times per week. according to the lawsuit. But Campbell alleges most of these members did not receive skilled nursing services at all in the week before United assessed their needs. and did not actually require the nursing services United said they did—steps the lawsuit says led to improperly inflated payments.
The complaint further alleges that inside the company, quality concerns were not resolved. It says United nurses responsible for making the member assessments repeatedly told their managers that evaluations “often included clinical assessments that were copied and pasted from prior evaluations of other patients. ” and that these assessments contained inaccurate diagnoses that did not reflect comprehensive reviews of each member’s health needs.
Campbell also points to staffing and incentives. She alleges United “chronically understaffed” the nurses. creating an incentive structure in which 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.”.
The lawsuit describes efforts by United to oversee assessments—and then. according to Campbell. the decision to loosen that scrutiny when pressure mounted. It says United created a quality control team to focus on member assessments before they were submitted to MassHealth. But Campbell alleges United “abandoned” the process for half of member assessments after a backlog threatened the company’s bottom line.
The alleged conduct spans years: Campbell’s complaint says the fraud occurred from 2015 through 2025 as MassHealth contracted with United to serve as a Senior Care Organization plan provider. The case is framed around how those assessments translated into higher payments for United.
For MassHealth, the timing couldn’t be more sensitive. Gov. Maura Healey’s budget proposal for fiscal year 2027 includes $22.7 billion for MassHealth. a 7 percent net increase from the current fiscal year. State spending is also rising. Total MassHealth spending is on track to have grown by $2.3 billion from fiscal year 2022 through fiscal year 2025.
The complaint’s allegations land against a backdrop of accelerating costs for older residents. Spending on long-term services and supports for older residents increased by 13 percent from 2024 to 2025 alone, according to state officials.
At this point. United’s position remains straightforward: it says the Attorney General’s complaint is wrong about the program and insists its Senior Care Options helps seniors with complex care needs meet their individual health needs. Campbell’s lawsuit. however. is built around a different picture—one in which assessments were handled in a way that. she alleges. pushed money higher while neglecting the quality controls meant to protect members and taxpayers.
Andrea Campbell UnitedHealthcare MassHealth Medicaid fraud Senior Care Options Senior Care Organization managed care plans skilled nursing services Massachusetts attorney general