Humana and UnitedHealthcare received a combined total of $177.8 million in Medicare Advantage overpayments tied to coding that was not supported by medical records, the HHS Office of Inspector General said in separate audit reports published Sept. 15.
The OIG’s recommendations are not final decisions, and CMS ultimately decides whether to pursue recoupment. Insurers also have the right to appeal.
Six notes:
- The larger of the two audits targeted HumanaChoice, a PPO plan that covered roughly 1.7 million enrollees as of December 2021. CMS paid the plan nearly $39 billion across the 2020 and 2021 payment years, and the OIG estimated overpayments of $130.9 million. The second audit covered UnitedHealthcare of Wisconsin, which covered about 676,000 enrollees over the same period and received roughly $16.6 billion from CMS. The OIG estimated $46.9 million in overpayments there.
- For Humana, 178 of 220 sampled cases lacked medical record support for the submitted diagnosis codes, an 81% error rate. At UHC, it was 183 of 250, a 73% error rate.
- The pattern of errors was virtually identical across both plans, with patients who had survived a stroke, beaten cancer, or recovered from a heart attack coded by providers as though their conditions were still active. At Humana, all 20 acute stroke cases sampled were in error, while UHC’s was 19 of 20 samples. Sampled cases for breast cancer, colon cancer and ovarian cancer showed similar results at both plans.
- Both audits also examined a category of potentially miskeyed diagnosis codes, where a data entry error appeared to have substituted one diagnosis for an entirely unrelated condition. At Humana, 10 of 20 sampled cases were unsupported, while 22 of 50 sampled cases at UHC were unsupported.
- Humana contested 69 of the cases identified as errors and rejected all four OIG recommendations. After further review, the OIG reversed nine of those contested cases. UHC contested 33 cases and asked the OIG to withdraw all its recommendations, of which eight were reversed. The insurer’s total error count was 183.
- Both insurers argued the audits were structurally biased because the OIG only looked for overpayments and didn’t consider diagnoses that may have gone unsubmitted and could have generated additional payments. They also challenged the OIG’s extrapolation methodology and argued the agency shouldn’t recommend clawbacks without applying a fee-for-service adjuster to account for the fact that coding errors also exist in traditional Medicare. UnitedHealthcare went further, arguing that CMS had already recovered the 2020 portion of the alleged overpayment through the MLR rebate process, noting it had paid $241 million to CMS under that mechanism for that year. The OIG rejected all those arguments.
“Humana takes its compliance responsibilities seriously and remains committed to working with CMS and policymakers to find ways to preserve affordable coverage and effective healthcare services for older Americans,” a spokesperson for the insurer told Becker’s. “Humana has a comprehensive approach to Medicare risk adjustment compliance.”
A UnitedHealth Group spokesperson told Becker’s that while it welcomes government reviews of its Medicare Advantage program, “we disagree with the current approach to validating data.”
“The flawed methodology in this report from the Office of the Inspector General is further evidence that modernization is needed, and we remain committed to working with both CMS and the OIG to improve the program and their audit processes,” the UnitedHealth spokesperson said.
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