Medicare Advantage Plans Overbill Medicare

A Humana Medicare Advantage plan in Florida improperly collected nearly $200 million in payments in 2015 by overstating how sick some of its enrollees were.  A new audit by the Department of Health and Human Services Office of the Inspector General (OIG) is seeking to get the money back.  If successful, the audit penalty would be what has been described as “by far the largest” ever imposed on a Medicare Advantage company.  But Humana has sharply disputed the OIG’s findings, and has said that the recommendations “do not represent final determinations, and Humana will have the right to appeal.”

The audit is part of long-delayed plans to recover money that the Centers for Medicare and Medicaid Services (CMS) says it overpaid to plans that exaggerated the severity of illnesses of patients treated.  The problem is one that the federal government has struggled with, unsuccessfully, for more than a decade.  According to one estimate that appeared in Health Affairs, CMS will overpay Medicare Advantage plans by $200 billion over the next decade if the current “coding intensity adjustment” system remains in place.

Popular with Medicare recipients, Medicare Advantage plans typically offer very low, or even no, monthly premiums, lower costs for some services than traditional fee-for-service Medicare, and coverage for some services that traditional Medicare does not cover, such as dental and vision care.  Enrollment in Medicare Advantage plans has more than doubled over the last decade, from 11.1 million in 2010, to 24.1 million in 2020.  Ensuring the proper payment level is important not only for the federal government, but also for beneficiaries, since overpayments to Medicare Advantage plans drive up overall Part B costs and cause higher Part B premiums for all beneficiaries, even those not enrolled in a Medicare Advantage plan.

Medicare Advantage plans contract with Medicare to provide all basic Medicare services, and plans receive monthly lump sum payments that cover expected costs for an average Medicare beneficiary.  But officials have known for years that some Medicare Advantage plans overbill the government by exaggerating how sick their patients are, or by charging Medicare for treating serious medical conditions that they cannot prove that patients have.  Audits of 37 health plans revealed that, on average, auditors could confirm only 60% of the more than 20,000 medical conditions that CMS paid plans to treat.

These overpayments occur because payments to plans are adjusted to pay more for older and sicker enrollees, and less for enrollees who are young and healthy.  As well  documented by the Medicare Payment Advisory Commission, Medicare Advantage plans use a variety of strategies to “document” enrollee medical conditions, including repeated, calls to homes in attempts to “update” health histories, and to schedule home visits from nurses to conduct health risk assessments even when patients have emphatically declined the visit.

TSCL believes a better approach to Medicare Advantage “risk adjustments” is needed, and should be written into law, rather than left to the discretion of politically appointed Medicare administrators.  Congress could do this by writing a method for calculating the adjustment into the law.  This approach would make payment for MA plans more like payment for other Medicare providers.


Sources:  “Humana Inc. Overcharged Medicare Nearly $200 Million, Federal Audit Finds,” Fred Schulte, NPR, April 20, 2021.  “Insurers Running Medicare Advantage Plans Overbill Taxpayers By Billions As Feds Struggle to Stop It,” Fred Schulte and Lauren Weber, Kaiser Health News, July 16, 2019.  “Reducing Medicare Advantage Overpayments,” Committee for a Responsible Federal Budget, February, 23, 2021.