4 Medicare Advantage plans audited for overpayments

HHS' Office of Inspector General has published audits of four Medicare Advantage plans in the past two months. 

The OIG frequently audits Medicare Advantage plans to determine if diagnosis codes submitted to CMS are in line with federal requirements. 

Diagnosis codes determine how much MA plans are reimbursed by CMS. Nearly every major Medicare Advantage plan has faced or settled allegations of upcoding, the practice of making patients appear sicker than they are on paper to receive higher reimbursements from CMS. 

In 2023, CMS implemented tougher auditing standards on Medicare Advantage plans. The move could leave payers on the hook for billions in repayment to the federal government. 

As part of the final rule, the OIG cannot request extrapolated overpayments from contract years prior to 2018. Many of the audits OIG has published this year are for contract years before 2018, so the agency requested a small portion of the full estimated overpayments. 

Humana is challenging the new auditing standards in court. 

Here are four insurers that received overpayments, according to OIG: 

1. EmblemHealth received an estimated $130 million in overpayments in 2015, the OIG found in an audit published Sept. 26. Because CMS cannot request extrapolated overpayments from contract years prior to 2018, the agency requested the $551,917 found in the sample in overpayments.
   
   "EmblemHealth complies with all CMS requirements and federal, state, and local regulations. EmblemHealth disagreed with OIG's audit findings and provided additional information resulting in OIG revising their initial report," an EmblemHealth spokesperson told Becker's.
   
   
2. Humana received an estimated $13.1 million in overpayments for one MA contract in 2017 and 2018, according to an OIG audit published Sept. 25. The audited contract served around 250,000 enrollees in 2018. The OIG requested $6.8 million in repayments.
   
   A Humana spokesperson told Becker's the company has "consistently called for CMS to audit every plan, every year using the right methodology that is consistent with the underlying principles of the Medicare Advantage model." In its response published in the OIG's report, Humana disputed the agency's audit methodology and disagreed with its recommendation to refund overpayments.
   
   
3. Aetna subsidiary HealthAssurance Pennsylvania received an estimated $4.2 million in overpayments between 2017 and 2018, according to an OIG audit published Sept. 25. The OIG recommended Aetna repay $4.2 million it received in overpayments.
   
   In a statement shared with Becker's, an Aetna spokesperson said the company "respectfully disagrees with the conclusions" of the OIG's audit.
   
   
4. MMM Healthcare, a Puerto Rico subsidiary of Elevance Health, received $59 million in net Medicare Advantage overpayments for 2017, according an OIG audit published Aug. 14. Elevance did not purchase MMM until 2021.
   
   The OIG recommended MMM repay $165,312. MMM disagreed with some of the audit's findings and disagreed with OIG's methodology.