On May 29, 2026, Massachusetts Attorney General Andrea Joy Campbell filed a lawsuit in Suffolk Superior Court accusing UnitedHealthcare of defrauding MassHealth — the state’s Medicaid program — out of more than $100 million by systematically making elderly, low-income patients look sicker than they were. The complaint, Commonwealth of Massachusetts v. UnitedHealthcare Insurance Company, runs 66 pages and is built on internal company documents, sworn testimony from United’s own employees, and interviews with former nurses. It paints a detailed picture of what the state calls a decade-long “growth at all costs” scheme.
Here’s what the complaint actually says, in plain English.
The program at the center of the case
The case focuses on United’s Senior Care Options (SCO) plan, a voluntary program for MassHealth members aged 65 and older. It combines Medicaid and Medicare benefits and, as of 2021, served a population that was over 90% community-dwelling rather than living in nursing homes. United is the largest SCO provider in Massachusetts, and between 2014 and the end of 2025 it was paid more than $5 billion by MassHealth for the plan.
Here’s the mechanism that drives the whole case. MassHealth doesn’t pay United per service. It pays a flat monthly amount per member — a “capitated rate” — and that rate depends entirely on how sick the member is rated. Members are sorted into three levels:
- Level 1 (Community Well) — the healthiest, lowest payment
- Level 2 (Behavioral Health) — a diagnosed behavioral health or substance use disorder
- Level 3 (Nursing Home Certifiable) — the most serious conditions, highest payment
The money gap between levels is enormous. For an Eastern Massachusetts member in 2025, MassHealth paid roughly $1,306 a month for Level 1, about $1,831 for Level 2, and over $4,265 for Level 3 — more than triple the lowest rate. So every member nudged up a level meant substantially more money for United.
Critically, United assigns the levels itself. Its nurses fill out a standardized assessment form (the MDS-HC), submit it to MassHealth, and MassHealth’s computer system assigns the level automatically based on United’s inputs. The state largely takes United at its word — it doesn’t have the resources to independently examine each senior. That trust is what the AG says United exploited.
The three schemes
The complaint lays out three distinct ways the state says United inflated its members’ levels.
1. Phantom behavioral health diagnoses (Level 2). To bill at Level 2, a member needs both a real behavioral health diagnosis and corresponding treatment. The AG alleges United routinely tagged members with conditions like depression or anxiety that had no support in their medical records — no diagnosis, no treatment, no prescription. The state’s own data analysis found that of the assessments United used to collect Level 2 payments between 2014 and 2024, nearly 30% had no matching behavioral health claim in the member’s records in the year before or after. One cited member, “S.W.,” kept being billed at Level 2 from 2021 onward based on a single 2018 depressive episode — even after her records confirmed she’d stopped medication because she felt better.
2. Unsupported “most serious” ratings United never paid back (Level 3). Beginning around 2014, the AG says United pushed many members into Level 3 who didn’t belong there. Then, starting in 2018–2019 — prompted in part by MassHealth audits — United quietly re-leveled large numbers of them down to Level 1, often with no documented change in the person’s actual health. The complaint’s position is blunt: these members weren’t re-leveled because they got healthier; they were re-leveled because they’d been wrongly coded in the first place. United never told MassHealth it had been overpaid, and never returned the money. The state pegs that bucket alone at more than $97 million in Level 3 payments before re-leveling.
3. Skilled nursing that never happened (Level 3). This is the most striking finding in the complaint. To qualify for Level 3 on the nursing pathway, a member has to actually need and receive skilled nursing care. United’s training materials and “cheat sheets” allegedly instructed nurses to always enter “7 days” of visiting nurse service for any member they wanted at Level 3 — regardless of whether the member got, or needed, any nursing at all. The numbers the AG pulled are staggering: of 88,696 Level 3 assessments United submitted from 2014 to 2024, 99.3% claimed seven-days-a-week nursing — but in nearly 90% of those, claims data showed the member hadn’t received a single nursing visit the prior week. For the subset where nursing was the only skilled service listed, the state says United collected at least $1.4 billion it wasn’t entitled to. Real members interviewed by the AG — identified as “J.C.,” “F.K.” and “L.P.” — said the only nurse contact they ever got was an annual check-in.
How the AG says it happened
What makes the complaint more than a billing dispute is the internal evidence of intent. According to the filing, United chronically understaffed its field nurses — managers who once supervised eight or nine nurses ended up overseeing more than twenty — while building an incentive structure where coding a member sicker meant fewer new patients added to a nurse’s caseload. Two Level 2 members counted as one Level 3 member for workload purposes, so over-leveling literally lightened the load.
Nurses described being trained to assess members based on their “worst day” rather than the last three days as the form requires, to treat any inhaler use as an automatic Level 3, and in one account to code every member over 79 at Level 3 regardless of ability. One nurse’s March 2021 resignation letter, quoted in the complaint, said she “was frequently asked to change documentation from my supervisor on assessments that was inaccurate to reduce company costs.”
United also had a quality-control team — the “MDS Team” — meant to catch these errors. The AG alleges that as a backlog built up in 2019, United told that team to stop auditing and just push assessments through, and by 2022 exempted roughly half of all assessments from any review at all, turning reviewers into what one called “data entry workers.” Internal chats capture the unease: one reviewer wrote that the new rules made her “eye twitch,” and another said, “I just think we cant be MDS Nurses and say we just submit.”
The pressure, the complaint says, came from the top. Bernadette Di Re, who ran the United SCO Plan from 2011 to 2020, attributed her resignation to corporate demands to “[g]et more numbers” and “[g]et more money from the state,” and testified she was publicly “lambasted” by a UnitedHealth Group executive for missing financial targets.
What United says
United denies wrongdoing. In public statements responding to the suit, the company called the case meritless and said it doesn’t accurately describe the senior care program, arguing the Attorney General is wrong to suggest Massachusetts seniors with complex needs shouldn’t receive the support the plan provides. These are allegations that have not been tested in court, and United is entitled to contest every one of them.
Why it matters beyond Massachusetts
The legal vehicle is the Massachusetts False Claims Act, which is a civil statute — so this is about money, not jail time. But the money can be large: the law allows the state to recover triple its actual damages plus civil penalties of $5,500 to $11,000 per false claim. With tens of thousands of assessments at issue, the penalty math alone could dwarf the $100 million headline figure. The complaint brings four False Claims Act counts plus common-law claims for unjust enrichment and breach of contract, and the state has demanded a jury trial.
The bigger significance is national. STAT and others have noted this is among the first cases to target alleged “upcoding” of dual-eligible patients — people on both Medicare and Medicaid — rather than Medicare Advantage alone. If the practices described in Massachusetts exist here, regulators in other states running similar managed-care programs have an obvious reason to start looking. A win for the Commonwealth could push insurers nationwide toward far tighter scrutiny of how they code the health of elderly and disabled members who are in no position to check what’s written about them.
The bottom line
Stripped down, the state’s case is that United told Massachusetts its elderly members were sicker, and needed more nursing care, than they actually were — collecting more taxpayer money each time — and then, when it found its own errors, kept the overpayments and quietly fixed the records going forward. Whatever a court ultimately decides, the complaint is a window into how a capitated payment system can be gamed when the company being paid is also the one grading the test.
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