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1Fix the driver behind crashes, sound loss and screen glitches2Clear out junk files and repair common Windows errors3Scan for outdated or missing drivers - takes under a minuteYes, UnitedHealth Group said in July 2025 that it was complying with formal criminal and civil requests from the Department of Justice (DOJ) concerning aspects of its Medicare participation. The latest concrete official development in the sources reviewed is a separate September 2026 audit by the Department of Health and Human Services Office of Inspector General (HHS-OIG). That audit found unsupported diagnoses in a sample from one UnitedHealthcare subsidiary’s Medicare Advantage contract and estimated at least $24.4 million in overpayments for 2020 and 2021. Neither the reported DOJ inquiry nor the audit establishes that a court has found UnitedHealth criminally liable for Medicare fraud.
What is publicly known about the DOJ investigation?
In a statement dated July 24, 2025, UnitedHealth Group said it had proactively contacted the DOJ after media reports and had begun complying with formal criminal and civil requests. The company said it would cooperate, expressed confidence in its practices, and stated, “We cannot predict the outcome of the government investigations.” Those are the company’s statements, not an independent finding about the inquiries or their outcome. UnitedHealth Group’s July 24, 2025 statement
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The Associated Press reported that earlier Wall Street Journal reporting described a civil inquiry into how UnitedHealth recorded diagnoses associated with Medicare Advantage payments and a criminal inquiry into how doctors and nurses gathered diagnoses. A DOJ Antitrust Division document separately characterized the Medicare billing investigations as involving alleged civil and criminal fraud and possible upcoding. These descriptions concern reported allegations and investigative focus; they do not establish that UnitedHealth or its personnel committed fraud. Associated Press, July 24, 2025; DOJ Antitrust Division filing TC-172
The sources reviewed do not establish whether DOJ has since closed or expanded its investigation, reached a settlement, or filed charges. UnitedHealth’s statement also cited independent CMS audits and a prior court-appointed Special Master’s review as support for its position; that is the company’s characterization and does not resolve the current DOJ inquiries.
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What did the 2026 HHS-OIG audit find?
HHS-OIG published a Medicare Advantage compliance audit on September 28, 2026, covering UnitedHealthcare Benefits of Texas, Inc., and contract H0609. It examined selected diagnosis codes submitted to the Centers for Medicare & Medicaid Services (CMS) for risk adjustment in 2020 and 2021. OIG reported that 172 of 230 sampled enrollee-years had diagnoses unsupported by medical records. The sample contained $622,927 in overpayments; based on those results, OIG estimated at least $24.4 million in overpayments for the two years. HHS-OIG audit summary, September 28, 2026
The report’s summary says United disagreed with some findings and asked OIG to withdraw its recommendations. OIG recommended a refund, but the reviewed summary does not establish whether the recommendations were finally resolved or repayment occurred. The $24.4 million figure is an extrapolated estimate, not the sample’s direct total or a final settled repayment amount.
How the DOJ inquiry differs from the OIG audit
| Question | DOJ inquiries | HHS-OIG audit |
|---|---|---|
| What kind of process? | UnitedHealth said it was responding to formal criminal and civil DOJ requests; media reports described possible diagnosis-coding and diagnosis-gathering inquiries. | A published compliance audit assessed selected diagnosis codes and recommended a refund based on its findings. |
| What is the scope? | Reportedly concerns aspects of UnitedHealth’s Medicare practices; the reviewed sources do not define the full scope. | UnitedHealthcare Benefits of Texas, Inc., contract H0609, selected diagnoses, and 2020–2021 payment years. |
| What is established? | UnitedHealth’s acknowledgment of formal requests and reported allegations; no current DOJ disposition is established in the reviewed sources. | Unsupported diagnoses in sampled enrollee-years and an OIG estimate of at least $24.4 million in overpayments. |
| Does this establish criminal liability? | No. An investigation or allegation is not a criminal judgment. | No. The audit is a specific compliance finding, not a criminal judgment about UnitedHealth as a whole. |
Why diagnosis coding affects Medicare Advantage payments
CMS pays Medicare Advantage organizations monthly, in part based on enrollees’ health status. Plans collect diagnosis codes from providers and submit them to CMS for risk adjustment. Because some diagnoses are more vulnerable to miscoding, unsupported codes can lead to overpayments. That payment mechanism explains the relevance of the Texas audit, but the audit’s results apply to its defined contract and sample—not automatically to every UnitedHealth plan or Medicare claim.
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