Several years ago, federal officials attempted to implement a regulation that would prevent Medicare Advantage insurers from overcharging the government by billions of dollars. The rule would have required insurers to identify overpayments and refund them to the government. However, the Centers for Medicare & Medicaid Services (CMS) abandoned the plan in 2014 due to pressure from the industry.
The decision by CMS and events related to it are now central to a multibillion-dollar civil fraud case against UnitedHealth Group, the largest Medicare Advantage plan provider in the nation. The Justice Department accuses the insurer of cheating Medicare out of over $2 billion by adding revenue based on additional diagnoses while ignoring overcharges.
Although UnitedHealth Group denies any wrongdoing, the case highlights ongoing issues with Medicare Advantage plans and their billing practices. The CMS has struggled to regulate these private health plans, which have faced numerous whistleblower lawsuits and government audits for potentially exaggerating patients’ illnesses to receive more payments.
The case involves accusations of invalid billing codes, with UnitedHealth Group allegedly failing to delete unsupported diagnoses and pocketing overpayments. The situation has raised concerns about the lack of oversight by CMS and the potential financial impact on taxpayers.
The case has led to a public release of thousands of pages of depositions and records, shedding light on the challenges faced by CMS in regulating Medicare Advantage plans. The outcome of the case could have significant implications for the industry and government oversight moving forward.
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