Audits reveal widespread Medicare Advantage overbilling

Insurance claims forms

Dozens of newly uncovered government audits dating back to 2007 reveal widespread overbilling among Medicare Advantage plans, particularly for beneficiaries with diabetes, drug or alcohol dependence, or depression.

The 37 audits, obtained by the Center for Public Integrity, showed that 40 percent of medical conditions were not confirmed by auditors, with higher rates for cases involving diabetes and depression. In many instances, payments were made for complications associated with diabetes that were non-existent based on the medical documentation provided.

Overpayments ranged from $2,000 to $10,000 per patient, but the sample size of the audits frequently encompassed hundreds, and sometimes thousands, of beneficiaries.

The newly revealed audits add to the handful of previously unreleased reviews that pointed to millions in overbilling linked to upcoded risk scores in Medicare Advantage plans. In 2014, government audits revealed that CMS overpaid as much as $32 billion between 2008 and 2010.

Several of the insurers listed in the audits—including Humana, UnitedHealth, and Wellpoint—are also facing whistleblower claims surrounding Medicare Advantage billing following an appeals court ruling that may have breathed new life into the lawsuit.

Officials with the Centers for Medicare & Medicaid Services told CPI that the agency expects to complete 30 audits of MA plans for 2011 claims, and plans to expand auditing in 2017. However, a spokeswoman for America’s Health Insurance Plans told the news outlet the audits were “not yet stable and reliable.”

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