Federal watchdog accuses Humana, UnitedHealthcare of upcoding
5 hours ago
- Two largest Medicare Advantage insurers, Humana and UnitedHealthcare, overcharged the government nearly $180 million in 2020 and 2021 by exaggerating member health needs.
- HHS OIG audits found that diagnosis codes submitted by HumanaChoice and UnitedHealthcare of Wisconsin were often unsupported by medical records, leading to overpayments of $131 million and $47 million respectively.
- The HHS OIG recommended refunds and improved compliance, but both insurers disagreed with the audit methodology and refuse to return the funds.
- The payment system creates incentives for upcoding, as insurers receive higher reimbursements for members with greater health needs.
- The audits focused on high-risk diagnosis codes for conditions like acute stroke, heart attack, embolism, and sepsis.
- Humana and UnitedHealthcare argue the audit methodology was skewed, while UnitedHealthcare has faced previous scrutiny for aggressive coding practices.
- CMS has taken some steps to curb upcoding, such as requiring diagnoses to be tied to actual medical encounters.