OIG: UnitedHealthcare banked $3.7B in Medicare Advantage payments in 2017 through chart reviews, HRAs

UnitedHealthcare banked $3.7 billion in Medicare Advantage by using health risk assessments and chart reviews to drive higher payments, according to the Department of Health and Human Services' Office of Inspector General (OIG).

The data stems from a report released last month that found MA plans overall were using these billing practices to juice their payments, to the tune of $9.2 billion. In the report, OIG said that one insurer brought in 40% of risk-adjusted payments through these methods despite accounting for just 22% of beneficiaries.

But, the analysis did not name the plan. However, the agency this week named UnitedHealth as the payer in question to the Minneapolis Star Tribune.

UnitedHealthcare said in a statement to Fierce Healthcare that the findings are "misleading."

"OIG’s report is based on old data and is inaccurate and misleading--a disservice to seniors and an attack on the CMS payment system," the insurer said. "In-home clinical care programs and chart reviews are needed for appropriate senior care and payment. UHC’s status as an early clinical home provider is not only appropriate, it’s best practice."

RELATED: OIG calls for more oversight as MA insurers bank $9.2B on the back of chart reviews, risk assessments

Open enrollment for Medicare is in its first week, and the market is hotter than ever. As MA space grows and profitability balloons, regulators have increasingly scrutinized the business practices insurers use in this market.

Detractors of current risk-adjustment models argue that insurers are incentivized to game the system, much like OIG alleges UnitedHealthcare did, to increase their payments—and that there is too little oversight of billing practices in the program.

The industry counters that Medicare Advantage plans allow for better care than traditional Medicare, especially given the flexibility these plans have to address social needs and manage chronic conditions.

Polling released earlier this year by the Better Medicare Alliance suggests that beneficiaries enrolled in MA plans have high satisfaction with the experience. A study published last week by the Commonwealth Fund found that MA beneficiaries report similar experiences as patients in traditional Medicare, such as how long they wait to see a doctor, but that MA did offer better care coordination.

In the September report, OIG called for the Centers for Medicare & Medicaid Services to more closely watch the 20 insurers in the report who accounted for the largest volume of claims driven by chart reviews and HRAs. 

In addition, OIG said its CMS counterparts should be monitoring the program to flag insurers who may be using similar methods to increase payments. CMS said it would consider the recommendations.

Amid a closer eye on the program in general, OIG specifically has turned up the heat in Medicare Advantage, launching investigations into major payers including Aetna and Anthem. CMS also earlier this year sanctioned several UnitedHealthcare and Anthem MA plans for failing to meet medical loss ratio requirements.