HHS-OIG says Humana's MA Plan Overcharged $34.4M

HumanaChoice says it 'strongly disagreed' with the audit, which found that 76% of claims 'were not supported in the medical records.'

Federal auditors are calling for Humana Inc. to refund $34.4 million in alleged overpayments made to the payer's HumanaChoice Medicare Advantage plan in 2016 and 2017.

The Department of Health and Human Services Office of the Inspector General, in an audit release this week, examined "nine high-risk groups" billed by HumanaChoice in 2016 and 2017 and found that 207 out of 270 (76%) randomly selected diagnosis codes with charges totaling 744,438  "were not supported in the medical records and resulted in $574,430 of overpayments for the 270 enrollee-years."

"These errors occurred because the policies and procedures that HumanaChoice had to prevent, detect, and correct noncompliance with CMS's program requirements as mandated by Federal regulations could be improved," OIG says. "On the basis of our sample results, we estimated that HumanaChoice received at least $34.4 million of overpayments for these high-risk diagnosis codes in 2016 and 2017."

The nine high-risk diagnosis codes are: acute stroke; acute heart attack; embolism; vascular claudication; major depressive disorder; lung cancer; breast cancer; prostate cancer; and colon cancer.  

The audit recommends that Humana refund the $34.4 million, identify similar instances of noncompliance for high-risk diagnoses before and after the audit period and refund any overpayments they find, and review existing compliance procedures to identify areas where improvements can be made.

Humana Rebuttal

Humana issued a statement saying it "strongly disagreed" with OIG's findings.

"Humana takes its compliance responsibilities seriously and remains committed to working with CMS and policymakers to find ways to preserve affordable coverage and effective healthcare services for older Americans," the payer says.

"Humana's response to the Office of the Inspector General of Health and Humana Services audit of R5826 is reflected in the published report, including how we strongly disagreed with the OIG's methodology and findings and that we have repeatedly shared our concerns about the methodology with CMS. As the OIG acknowledges, its findings and recommendations do not represent final determinations."   

On Monday, OIG released a similar audit of Highmark Senior Health Company, and identified $6.2 million in overpayments. Highmark also disagreed with the findings.