HHS' Office of Inspector General estimated three Medicare Advantage insurers received around $11.4 million in overpayments.
The government watchdog published audits of three MA plans Dec. 23-26. The agency estimated:
- UCare received at least $4.7 million in overpayments between 2018 and 2019.
- Blue Care Network of Michigan, part of BCBS Michigan, received at least $6.4 million in overpayments over 2017 and 2018. Because CMS can only request estimated repayments for plan year 2018 onward, the agency only requested the company repay $3.4 million for 2018.
- Triple-S Advantage, a subsidiary of Guidewell, received $296,758 in overpayments.
The OIG frequently audits Medicare Advantage plans to determine if diagnosis codes submitted to CMS are in line with federal requirements. The agency has published audits of at least four other insurers in 2024.
Diagnosis codes determine how much MA plans are reimbursed by CMS. Nearly every major Medicare Advantage plan has faced or settled allegations of upcoding, the practice of making patients appear sicker than they are on paper to receive higher reimbursements from CMS.
All three insurers audited did not agree with the OIG's recommendations. In a statement shared with Becker's, a UCare spokesperson said the company identified "flaws" in the OIG's methodology. The agency did not calculate potential underpayments, the spokesperson said, only overpayments.
"We found the value of underpayments associated with just one condition – congestive heart failure – was enough to offset the overpayment identified by the OIG for the 10 'high risk' diagnoses audited," the spokesperson said.
"UCare respectfully requested the OIG withdraw its recommendations and apply a more balanced approach to promote parity and fairness in the audit process," the spokesperson added.
Becker's has reached out to representatives for BCBS Michigan and Guidewell for comment, and will update this article if more information becomes available.