Medicare Advantage Money Grab

Published — June 17, 2015

Audit: Feds overpaid for half of patients in UnitedHealth Medicare Advantage plan

A portion of The UnitedHealth Group Inc.'s campus in Minnetonka, Minn. Jim Mone/AP

Giant insurer disputed 2012 findings in secret legal proceeding


Federal officials spent years locked in a secret legal battle with UnitedHealth Group, the nation’s biggest Medicare Advantage insurer, after a government audit detected widespread overbilling at one of the company’s health plans, newly released records show.

The audit, completed in 2012, found that Medicare had paid too much for nearly half of a sample of patients enrolled at PacifiCare of Washington State, a subsidiary of UnitedHealth Group. The heavily redacted audit was part of a cache of documents recently released to the Center for Public Integrity through a court order in a Freedom of Information Act lawsuit.

Matt Burns, a UnitedHealth spokesman, declined comment. However, during more than three years of confidential — and previously undisclosed — negotiations, the insurer argued the audit was unfair and the results were flat out wrong.

These audits are called Risk Adjustment Data Validation, or RADV. They test the accuracy of a billing tool called a “risk score.” Medicare uses risk scores to pay health plans higher rates for sicker people and less for those with few medical needs. But federal officials concede that some health plans may overstate how sick their patients are, a practice known as “upcoding,” that wastes billions of tax dollars every year. The RADV audits are designed to recover any overcharges.

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K CarsonThomas Jamesondoctors in San Antonio TX Recent comment authors
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doctors in San Antonio TX

I really appreciate your professional approach. These are pieces of very useful information that will be of great use for me in future.

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Thomas Jameson

It’s good to know that private Medicare health plans have caused an increase in the number of doctors performing house calls. My parents are getting old, and they can’t get out of the house very well to go see a doctor whenever something happens to them. I’ll pass this information along to them so that they can look into their options for Medicare plans that include house calls.

Charles Dietrich
Charles Dietrich

I was shocked to see how much ($325) my Aetna plan paid for my “house call.” The doctor was at my home, I’d say, for 10 minutes, and couldn’t get out fast enough. The only “exam” that I recall was a blood pressure test with a little wrist band. The bp he got was much higher than my normal pressure, but he didn’t seem to be all that interested. I don’t recall that he did anything else like listening to my heart and lungs, although I’m not positive about that. He was mostly trying to get information like a list… Read more »

K Carson
K Carson

This is information that the American public needs to be far more aware of, rather than the daily drama distractions of Washington politics that have no direct effect on most people’s lives. Knowing how medical coverage/billing operates for Medicare provides a much-needed perspective on something that many take for granted — including their assumption that health insurance is a good thing. Tallying the horror stories from all sides of healthcare (patients, medical staff, government payouts to insurance, etc.), only highlights how much better off we all would be WITHOUT insurance interference. The government’s inability to regulate overpayments that they are… Read more »