An audit by the Department of Health and Human Services’ Inspector General’s Office (OIG) discovered that UnitedHealthcare and HumanaChoice overcharged the government in Medicare payments by $180 million between 2020 and 2021.
The companies cover about 15 million seniors.
The government pays private insurance companies a “a per member, per month fee” for Medicare seniors.
The government adjusts fees based on a member’s health needs to ensure patients who need the money receive it.
However, the process could lead companies to exaggerate members’ “health needs to receive higher reimbursement, a practice known as upcoding.”
- Plans operated by the two largest Medicare Advantage [MA] insurers jointly overcharged the government almost $180 million in 2020 and 2021 by exaggerating the health needs of their members, according to new audits from a federal watchdog that could intensify concerns about insurers gaming the privatized Medicare program.
- HumanaChoice and UnitedHealthcare of Wisconsin frequently submitted diagnosis codes to Medicare that weren’t backed up by medical documentation, generating an extra $131 million and $47 million in reimbursement, respectively, over the two years, according to the HHS Office of the Inspector General.
- The HHS OIG suggested that the insurers refund the estimated overpayments to the CMS and beef up compliance procedures to make sure they’re not submitting unsupported codes. Humana and UnitedHealthcare both said the audit methdology was flawed and that they don’t plan to return the funds.
The high risk includes:
- Acute stroke
- Acute myocardial infarction
- Embolism
- Lung cancer
- Breast cancer
- Colon cancer
- Prostate Cancer
- Ovarian cancer
- Sepsis
- Pressure Ulcer
The OIG examined 220 enrollees at HumanaChoice in those high-risk groups.
The findings showed medical records did not support 178 of them, equating “to almost $670,000 in overpayments, or about $130.9 million when extrapolated to HumanaChoice’s entire contract.”
The audit covered 250 UnitedHealthcare enrollees. Out of 250, 183 did not match the medical records, leading to “$722,000 in overpayments, causing the enforcement agency to estimate the plan received at least $46.9 million in improper reimbursement for 2020 and 2021.”
[Featured image via YouTube]
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