What UnitedHealth’s Expanding DOJ Probe Means for the Rest of Us

When UnitedHealth eventually confirmed it was under formal federal scrutiny, many assumed the investigation would center primarily on Medicare Advantage billing practices. Over time, however, it’s become clear that the inquiry is broader than many first believed—and that has meaningful implications for compliance teams, not just across UnitedHealth, but for anyone operating in similar regulatory spaces.

What’s New: The Investigation Widens

Originally, the Department of Justice (DOJ) probe focused on whether UnitedHealth had inflated risk scores or otherwise misrepresented diagnoses to gain higher Medicare payments.

Recent reports show the investigation now also covers:

• Prescription management practices via Optum Rx — how UnitedHealth’s PBM handles prescriptions and whether there are concerns around how it reimburses or deals with its own employed physicians.

  
  

• Medicare business broadly — it's not just individual diagnosis coding; the DOJ is looking at billing, managed care practices, and how UnitedHealth interacts with providers and beneficiaries in its Medicare segments.

UnitedHealth has publicly stated that it’s cooperating with both criminal and civil inquiries. It has also initiated internal reviews of its billing practices.

Why Broader Scope Matters

For compliance professionals, the expansion of the probe brings several issues into sharper relief:

1. Multiple dimensions of risk

   A probe focused just on diagnosis coding is one thing. But when you add PBM operations, provider reimbursement, and prescription management, you introduce more actors, more contracts, more processes—and more potential gaps.

   
   

2. Interconnected business lines under scrutiny

   UnitedHealth is large, with Optum and UnitedHealthcare covering insurance, pharmacy benefits, provider networks, and more. When investigations span multiple segments, even practices that seem isolated (e.g., how a PBM treats prescriptions from employed vs. outside physicians) may suddenly get pulled into regulatory scrutiny.

   
   

3. Compliance posture and documentation are even more critical

   With civil and criminal components, what looks like minor billing policy ambiguity or contract language could become a source of exposure if documentation, internal audits, and oversight aren’t clean.

   
   

4. Precedent effect

   When a large player like UnitedHealth is under this kind of multifaceted investigation, it raises awareness among regulators—and that often leads to more oversight across markets. Smaller organizations may see similar questions raised about their Medicare Advantage programs, PBMs, or provider‑contracting practices.

   
   

What to Watch

While the UnitedHealth case plays out, here are key compliance questions everyone should be asking in their own organizations:

• Are your risk adjustment / diagnosis coding practices well documented and defensible?

  
  

• Does your PBM (or other pharmacy‑management operations) have robust oversight, especially in how it handles in‑house vs external provider relationships?

  
  

• How are internal reimbursements or physician compensation structured? Could they inadvertently create incentives or conflicts of interest?

  
  

• What does your internal audit process look like across business lines? Are there “blind spots” where risks might be lurking?

  
  

• How ready is your organization to respond if asked for documents, contracts, communications—especially between divisions?

  
  

Compliance is rarely static. This expanding probe reminds us that what looked “settled” can shift. The best defense continues to be transparency, strong process controls, good documentation, and a culture that sees compliance as a proactive foundation—not just a reaction after something shows up in the press.