OIG calls for Humana, Aetna subsidiary to repay millions in MA overpayments

The Biden administration is pressing Humana and CVS to refund millions in Medicare Advantage (MA) overpayments, according to several audits released by the Department of Health and Human Services Office of Inspector General (OIG).

The agency is requesting the highest refund from Humana based on a random sample of 240 unique enrollee years. OIG estimates that based on this sample, the insurer received at least $13.1 million in overpayments in 2017 and 2018 and is seeking a $6.8 million refund.

Federal regulations do limit using risk adjustment data validation (RADV) audits for recovery purposes before 2018, which explains the discrepancy between the overpayment estimate and recommended refund, OIG said.

OIG also identified a random sample of 269 unique enrollee years at HealthAssurance Pennsylvania, a subsidiary of CVS Health's Aetna. Through that audit, the agency estimated that HealthAssurance received $4.2 million in overpayments in 2018 and 2019.

The feds are recommending that CVS refund the $4.2 million. In addition to the refunds, OIG is urging the payers to identify further noncompliance outside of the audit period while also continuing to monitor compliance and take steps to correct any issues.

Both insurers disagreed with some of the findings and neither concurred with the recommendations.

Potential overpayments in the MA program have been under significant scrutiny, both from the Centers for Medicare & Medicaid Services (CMS) and in Congress. CMS also finalized in February 2023 a significant overhaul to risk adjustment audits, which drew ire from insurers.

Humana filed suit to challenge the RADV updates in September 2023, and the case remains ongoing.