The disadvantages of Medicare Advantage programs can extend beyond frustration for patients and lower reimbursement rates for hospitals.

A recent report from the U.S. Health and Human Services Department Office of Inspector General put a sharper focus on questionable practices in certain Medicare Advantage programs from certain commercial health insurance companies. Three health insurance companies were found to have used codes that did not match patient medical records yet secured more than $140 million in federal reimbursements.

From the article:

Humana, HealthAssurance Pennsylvania — a unit of CVS Health subsidiary Aetna — and EmblemHealth deny the accusations and reject the OIG’s recommendations that the Centers for Medicare and Medicaid Services recoup a portion of the alleged overpayments.

According to the OIG reports, the three insurers misused diagnosis codes to generate higher federal reimbursements under the Medicare Advantage risk-adjustment program. The agency:

• Estimates that EmblemHealth received at least $130 million more than it should have in 2015
• Alleges Humana collected at least $13.1 million too much in 2017 and 2018; and
• HealthAssurance received $4.2 million more than they should have in 2018 and 2019.

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