CMS dropped a proposed regulation that would have required Medicare Advantage plans to return overpayments found during chart reviews over industry opposition, KFF reported Aug. 27.
In 2014, CMS proposed a rule that would require health plans reviewing patients' medical records to identify potential overpayments and return them to CMS. CMS dropped the proposed rule later that year.
Records released from a 2022 deposition show CMS officials decided to abandon the rule over concern from insurers, KFF reported. The rule change is at the center of a civil fraud case against UnitedHealth Group that has been pending for more than a decade.
In records recently made public, CMS officials said they decided not to move ahead with the regulation because of "stakeholder concern and pushback."
The case was filed in 2011 by a former UnitedHealth employee and was taken over by the Justice Department in 2017, according to KFF. The Justice Department alleges it paid UnitedHealth $2.1 billion between 2009 and 2016 from unsupported billing codes, which it says UnitedHealth should have removed.
Because the proposed rule was not finalized, UnitedHealth said in court filings it should not be penalized for failing to follow a regulation CMS did not adopt, according to KFF.
Don Berwick, MD, a former CMS administrator, told Becker's in February the "political forces that the agency has to contend with have and will push back hard on these changes."
"CMS needs a lot of support and encouragement from the administration and the public to continue on this journey, though I wish they would go faster and take on even more," he said.
Nearly every major payer has been accused of or settled allegations of upcoding, the practice of making patients appear sicker than they are on paper to receive higher reimbursements from CMS.
The Justice Department and CMS declined to comment to KFF. A spokesperson for UnitedHealth told the news outlet its "business practices have always been transparent, lawful and compliant with CMS regulations."
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