Medicare Advantage Overpayments: OIG Audit Highlights Humana's Financial Challenges

The Office of Inspector General (OIG) conducted an audit revealing that Humana's operations in Louisiana incurred significant Medicare Advantage overpayments during 2017 and 2018. This audit, focusing on high-risk diagnosis codes such as acute stroke and myocardial infarction, identified over $553,000 in overpayments from a sample of 240 enrollee-years. Extrapolating from this data suggests an estimated $10.5 million in overpayments during the audit period.

Of the 240 cases reviewed, 218 had unsupported diagnosis codes, primarily errors in documenting medical history rather than active conditions. Humana has rejected the OIG's findings and emphasizes the importance of comprehensive audits of all plans using consistent methodologies aligned with Medicare Advantage principles. These disputes highlight industry challenges in maintaining regulatory compliance and financial accuracy within payer-provider frameworks.

The OIG recommended that Humana repay $5.5 million based on federal regulations limiting extrapolation for payment recoveries from 2018 onwards. As of now, the Centers for Medicare & Medicaid Services (CMS) will decide on any necessary repayments and initiate recoupments if justified. This scenario underlines the critical need for robust risk management and regulatory compliance measures within the Medicare Advantage system, ensuring that financial audits uphold integrity and accuracy throughout the sector.