KFF Health NewsAug 27 2024 A decade ago, federal officials drafted a plan to discourage Medicare Advantage health insurers from overcharging the government by billions of dollars — only to abruptly back off amid an "uproar" from the industry, newly released court filings show.
The Justice Department alleges the giant health insurer cheated Medicare out of more than $2 billion by reviewing patients' records to find additional diagnoses, adding revenue while ignoring overcharges that might reduce bills. The company "buried its head in the sand and did nothing but keep the money," DOJ said in a court filing.
"It’s easy to dump on Medicare Advantage plans, but CMS made a complete boondoggle out of this," said Richard Lieberman, a Colorado health data analytics expert. The proposed January 2014 regulation mandated that chart reviews "cannot be designed only to identify diagnoses that would trigger additional payments" to health plans.
"So we did not move forward then," she said. "Not because we didn't think it was the right thing to do or the right policy, but because it had mixed reactions from stakeholders." DOJ alleges Medicare paid the insurer more than $7.2 billion from 2009 through 2016 solely based on chart reviews; the company would have received $2.1 billion less if it had deleted unsupported billing codes, the government says.
The complex case has featured years of legal jockeying, even pitting the recollections of key CMS staff members — including several who have since departed government for jobs in the industry — against those of UnitedHealthcare executives. "All I can tell you is I remember feeling very uncomfortable in the meeting," Rice said in her 2022 deposition.