UnitedHealthcare received $24M in Medicare Advantage overpayments in Texas: OIG

UnitedHealthcare’s Medicare Advantage business in Texas received an estimated $24.4 million in overpayments during 2020 and 2021 tied to diagnoses not supported by medical records, the HHS Office of Inspector General said in an audit report published Sept. 28.

The report follows an OIG audit released a week prior that estimated UnitedHealthcare’s Wisconsin MA business received $46.9 million in overpayments over the same two years. 

The OIG’s recommendations are not final decisions, and CMS ultimately decides whether to pursue recoupment. Insurers also have the right to appeal.

Five notes:

1. The audit examined a UnitedHealthcare MA plan that covered about 339,000 enrollees in Texas as of December 2021 and received roughly $8.8 billion from CMS across the 2020 and 2021 payment years.
   
   
2. Of 230 sampled cases, 172 lacked medical record support for the submitted diagnosis codes, or a 75% error rate. The Wisconsin plan’s error rate was 73%. The OIG found $622,927 in overpayments from the sampled cases in Texas and estimated the total at $24.4 million after extrapolating across the broader population.
   
   
3. The errors followed the same pattern seen in Wisconsin, with patients coded as having active conditions when their records showed only a history of them. Acute stroke and prostate cancer each had 19 of 20 sampled cases in error, while lung, breast, colon and ovarian cancer each had 18 of 20. UnitedHealthcare also could not locate medical records for three of the sampled cases.
   
   
4. The OIG noted that UnitedHealthcare had a data filter designed to block unsupported acute stroke codes, but it applied only to codes from in-home health visits and chart reviews, not to codes submitted directly by providers.
   
   
5. UnitedHealthcare contested 25 of the cases identified as errors and asked the OIG to withdraw all four of its recommendations. The OIG reversed nine of the contested cases, reducing the original error count from 181 to 172. The insurer argued the audit ignored potential underpayments, relied on samples too small for reliable extrapolation and should have applied a fee-for-service adjuster, which the OIG rejected.

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