4 recent Medicare Advantage overpayment cases

The Cigna Group will pay over $170 million to settle allegations of Medicare Advantage fraud, and government watchdogs are auditing other plans for potential overpayments. 

Nearly every major insurer has been accused of or settled allegations of receiving Medicare Advantage overpayments through upcoding, or making patients appear sicker than they are on paper to receive higher reimbursements from the government. 

Here are four insurers audited for MA overpayments or settling allegations of fraud Becker's has reported since July. 

  1. Aetna received $632,070 in overpayments for Medicare Advantage claims from 2015 to 2016, an audit from HHS' Office of Inspector General found. The OIG used the audit sample to estimate the insurer received at least $25.5 million in overpayments during the time period.

    Aetna did not concur with OIG's recommendations or findings in the audit, according to the report. The company also disputed the audit's methodology.

    "We note that, while OIG identified an overpayment amount across our entire contract, that recommendation is not consistent with CMS regulations and is not applicable to the audit at issue. However, we are pleased that OIG recognized the efforts we put into our compliance program," an Aetna spokesperson said in a statement shared with Becker's. 

  1. The Cigna Group will pay $172.3 million to resolve allegations that it violated the False Claims Act by submitting incorrect Medicare Advantage patient data to CMS to receive higher payments from the agency.

    As part of the settlement, Cigna has entered into a five-year accountability and auditing agreement with HHS' Office of Inspector General, which will require company executives and board members to certify Cigna's compliance moving forward. The payer must also conduct annual risk assessments and submit to independent risk adjustment audits.

    "These agreements fully resolve long-running legal matters, enabling us to focus our resources on all those we serve and avoiding the uncertainty and further expense of protracted litigation," Chris DeRosa, president of Cigna Healthcare's U.S. government business, said Sept. 29. 

  1. Presbyterian Health Plan received an estimated $2.2 million in Medicare Advantage payments in 2017 and 2018, according to an audit from HHS' Office of the Inspector General.

    The audit sampled 211 enrollee-years for seven high-risk diagnosis codes. The audit sample found $442,454 in overpayments. OIG used the audit sample to calculate the $2.2 million estimate.

    Presbyterian Health Plan did not concur with OIGs findings. In its response to the audit, the plan said OIG overstated the amount of overpayments and used a flawed audit process and methodology.

  1. Martin's Point Health Care agreed to pay $22.5 million to resolve allegations that it knowingly submitted inaccurate diagnosis codes for Medicare Advantage Plan enrollees to increase reimbursements from Medicare.

    Prosecutors alleged that the Portland, Maine-based system — which operates Medicare Advantage plans for beneficiaries in Maine and New Hampshire — reviewed charts of their Medicare Advantage beneficiaries to identify additional diagnosis codes that had not been submitted to Medicare. 

See more insurers audited for upcoding earlier in 2023 here. 

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