UnitedHealth Group — one of the largest health insurers and Pharmacy Benefit Managers (PBMs) in the country — is now under federal investigation for its Medicare Advantage (MA) business practices.

UnitedHealth Under Federal Investigation for Medicare Advantage Fraud  – APnews.com Online Article (July 24, 2025)

This includes both civil and criminal probes into billing practices that may have led to inflated taxpayer-funded reimbursements.

In a recent Securities and Exchange Commission (SEC) filing, UnitedHealth acknowledged it is cooperating with the U.S. Department of Justice following reports of potential fraud involving how the company records diagnoses to maximize Medicare Advantage payments. These private MA plans cover over 8 million Americans — mostly seniors — and are a core business line for UnitedHealthcare, a division of UnitedHealth Group.

What’s Being Investigated?

According to The Wall Street Journal, federal investigators are scrutinizing how UnitedHealth used doctors and nurses to gather diagnoses that may have artificially increased payments from the Centers for Medicare & Medicaid Services (CMS). These upcoding practices can lead to significant overpayments and have long been a controversial tactic in the Medicare Advantage market.

The situation escalated in recent months, with a federal criminal healthcare fraud unit reportedly involved in investigating the company’s conduct.

Fallout and Financial Instability

While UnitedHealth claims confidence in its internal compliance, the company’s public performance suggests otherwise:

• The company withdrew its earnings forecast in May, citing rising medical costs — particularly from newly enrolled Medicare Advantage patients.

• Its stock price has fallen more than 55% since peaking last November.

• High-profile leadership turmoil followed, including the resignation of CEO Andrew Witty and the tragic shooting death of UnitedHealthcare CEO Brian Thompson in December 2024.

UnitedHealth’s business model — which spans health insurance, PBM operations, and care delivery through Optum — generated over $400 billion in revenue last year. But its reliance on Medicare Advantage growth and aggressive billing practices now face major scrutiny.

Why Independent Pharmacies and Injured Workers Should Care

This case underscores the growing concern about vertical integration in the healthcare industry — where insurance giants also own PBMs and provider networks. This consolidation often leads to anti-competitive practices that hurt independent providers and patients alike.

At RescueMeds, we’ve long warned about the unchecked power of PBMs, especially those embedded within conglomerates like UnitedHealth. From reimbursement clawbacks to restricted pharmacy networks, these practices limit access to care — especially for injured workers and vulnerable patients.

What Comes Next?

As federal authorities dig deeper, there is growing momentum for transparency and reform in both the Medicare Advantage and PBM sectors. For independent pharmacies, providers, and patients, this investigation may serve as a wake-up call — and a long-overdue opportunity for structural change.

RescueMeds will continue to monitor these developments and advocate for fair, patient-focused healthcare delivery, especially in workers’ compensation.