UnitedHealth Schools Senate Committee on Patient Risk Scoring

The investigators said they reviewed about 50,000 pages of documents provided by UnitedHealth to create their report. They cited no new evidence in the report that UnitedHealth plans lied about the Medicare plan enrollees' health or violated Medicare risk scoring rules, but they suggested that some of UnitedHealth's "coding intensity" might not be clinically appropriate and might constitute "gaming" of the risk scoring system.

UnitedHealth said in a statement that it disagrees with the committee's characterization of its Medicare Advantage coding practices and of a UnitedHealth program that sends nurse practitioners to Medicare plan enrollees' homes to assess their health.

"Our programs comply with applicable CMS requirements and have, through government audits, demonstrated sustained adherence to regulatory standards," UnitedHealth said. "Our programs are subject to rigorous clinical quality controls and compliance safeguards."

The backdrop: The Senate Judiciary staff report has appeared as President Donald Trump and Republicans in Congress are citing what they say are high profit levels at health insurers to justify health insurance subsidy cuts.

A temporary increase in the federal subsidy levels for individual and family health insurance premiums expired Dec. 31, 2025. House Democrats and 17 House Republicans joined to pass a bill that could extend the 2025 premium subsidy levels for three years. The Senate is now considering the bill.

Rep. Brett Guthrie, R-Ky., the chairman of the House Energy and Commerce Committee, told the supporters of the subsidy boost extension bill on the House floor that he opposed that bill but would bring in health insurance company executives to have them explain why health insurance premiums are so high.

The committee has invited Stephen Hemsley, the chief executive officer of UnitedHealth, and the CEOs of three other big health insurers — Cigna, Elevance and CVS Health, the parent of Aetna — to testify at a hearing Jan. 22.

What it means: The new Senate Judiciary Committee report on UnitedHealth's risk scoring could be part of what the newspaper The Hill has described as "insurers' time in the barrel."

In the long run, congressional interest in health insurance strategies and costs could improve clients' health coverage and lower the cost.

In the short run, the scrutiny could lead to more turmoil in the health insurance market and more challenges for clients who are trying to keep high-quality, high-value health coverage in place.

Medicare Advantage: The traditional Medicare program was created in 1965. It exposes enrollees to many deductibles, coinsurance and copayment requirements.

The 69 million enrollees can fill in the holes by buying Medicare supplement insurance policies, or Medigap policies, from private insurers. Congress created a standard framework for Medigap policies in 1992, but states are in charge of regulating Medigap issuers and sellers. About 14 million people have Medigap policies.

About half of the enrollees use Medicare Advantage managed care plans to fill in traditional Medicare gaps. Those plans are regulated by the federal Centers for Medicare and Medicaid Services.

The issuers cannot exclude sick patients or limit their coverage.

The federal government pays the issuers an amount similar to what it would spend on traditional Medicare claims for the Medicare Advantage plan enrollees. The government tries to compensate issuers that end up with more than their fair share of sicker enrollees by paying higher rates for higher-risk patients.

In the Medicare Advantage enrollee risk scoring system, the score for a typical enrollee is about 1.

The score for an enrollee with a condition such as severe arthritis, who might have health care costs that are about twice as high as the costs for an average Medicare enrollee, is about two.

In some cases, for older, very sick patients with multiple serious conditions, such as a combination of cancer, emphysema, dementia and heart disease, the risk score might be 6 or higher, and the expected claims might be more than six times the average claim level.

The committee report: Much of the Senate Judiciary investigators' report focuses on details about how UnitedHealth "codes" specific types of patient health risk, such as obesity, chronic respiratory failure and rheumatoid arthritis.

The company employs a large patient health risk assessment team, sells patient risk assessment services to other health coverage providers, and publishes and sells guides to patient risk assessment, the investigators said.

In the section on risk assessments for patients with rheumatoid arthritis, the investigators reported that the nurse practitioners who handled UnitedHealth's home-based patient risk assessments during the period under review watched for signs that patients had rheumatoid arthritis even when the patients' physicians had not recorded rheumatoid arthritis diagnoses.

The nurse practitioners would look, for example, to see if patients had fingers bent in a shape that resembled a swan's neck. A "swan neck deformity" can be a sign of rheumatoid arthritis, an injury or other conditions.

UnitedHealth's team would search for evidence that a patient with swan neck deformity might have rheumatoid arthritis, according to the new report.

UnitedHealth has also taught the risk assessment providers that rheumatoid arthritis "can be used to support a diagnosis of immunodeficiency due to conditions classified elsewhere," and it encouraged the providers to classify nerve problems in patients with rheumatoid arthritis as "rheumatoid polyneuropathy" rather than as simple "polyneuropathy," according to the report.

UnitedHealth's reports: UnitedHealth hired Milliman, an actuarial consulting firm, to produce a detailed report on the value of the Medicare Advantage program to the federal government and a second report on annual enrollee costs for Medicare enrollees with different types of coverage.

The value analysis shows that Medicare Advantage plans get an average of $1,117 per enrollee per month from the federal government, or 9% less than what the federal government spends on traditional Medicare enrollees.

The average cost of administration and profits is about $139 per enrollee per month at the Medicare Advantage plans, compared with average administrative costs of just $15 per enrollee per month at traditional Medicare, but the Medicare Advantage plans are so much more efficient that they can spend an average of $188 per enrollee per month on extra services, such as dental coverage, according to the analysis.

Some analysts have suggested that spending on Medicare Advantage enrollees is lower because people who sign up for these plans tend to be healthier than traditional Medicare enrollees, but the Milliman analysts said Medicare Advantage plans would still be less expensive for the government, after adjustment for enrollee health, even if their enrollees were about 10% healthier than traditional Medicare enrollees.

The Milliman enrollee cost report includes a table showing average premiums, average enrollee out-of-pocket costs and average Medigap policy premiums in all 50 states and the District of Columbia.

In Alabama, for example, the average premium for a Medicare Advantage plan with prescription coverage was $2,266 per year in 2025, the average out-of-pocket cost for the enrollees was $1,431 per year, and the average premium spending for Medigap plan G coverage is $6,060 per year.

For the enrollees, combining traditional Medicare coverage with a stand-alone drug plan and a Medigap plan G policy is more than twice as expensive as getting a Medicare Advantage plan that includes drug coverage, according to the analysis.

UnitedHealth's own coding concerns: Although some parts of UnitedHealth collect cash based on risk scores from the federal government, other parts pay physicians, hospitals and other health care providers based on procedure and diagnosis codes.

UnitedHealth's own businesses sometimes go to court when they believe providers are using aggressive coding strategies to make patients look sicker than they are. UnitedHealth's UnitedHealthcare unit is currently suing Team Health, an emergency services provider, over coding intensity concerns in the U.S. District Court for the Eastern District of Tennessee.