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Oops, Humana did it again

Did a Humana “billing oversight” result in the government being overcharged hundreds of millions of dollars? Modern Healthcare’s April 20 coverage sums up the latest in a series of stories about insurers accused of behaving badly with Medicare Advantage.

Is it just us, or do health insurers seem to be, um, taking advantage of Medicare Advantage (MA)? This year alone, we’ve seen stories about Cigna and Anthem hitting stop signs on their way from MA to the bank. And now Humana’s in hot water too. With 4.6 million MA lives in the insurer’s grasp, that’s big news (Humana, by the way, is the second-largest MA insurer in the nation next to United).

A recent government audit found that in 2015 Humana (over)charged the Centers for Medicare and Medicaid (CMS) to the tune of $200 million—yes, you read that right, $200 million—for MA care.

An auditor working for the Office of the Inspector General (OIG) looked at a random sample of Humana’s MA enrollees and was unable to find evidence that 200 of the conditions listed in the diagnosis codes for these members existed, leading officials to believe that Humana overcharged CMS for a sizeable portion of their care. The OIG extrapolated these “billing errors” across Humana’s entire MA book of business for the year to arrive at the amount of money that it believes Humana should return to CMS.

While Humana claims it’s cooperating with the OIG, a company spokesperson took issue with the audit’s methods, as well as the findings of the audit report.

We have so many questions. Will Humana be held accountable? What would the OIG uncover if it audited subsequent years of Humana’s MA business? Are other insurers making similar “errors”?
And most important of all, as MA grows, will the government be able to keep tabs on the insurers running the program?

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