Report Finds MA Plan Might Have Received $424M in Overpayments

A Medicare Advantage plan run by PacifiCare of California might have received nearly $424 million in overpayments as a result of improper patient diagnosis codes, according to a report from HHS' Office of Inspector General, California Watch reports.

Details of the Report

For the report, investigators reviewed a 2007 contract between PacifiCare and CMS, under which the insurer received $2.3 billion to administer care for more than 188,000 patients.

They analyzed a selection of 100 patient charts with risk scores, diagnostic codes and related health records.

Key Findings

The researchers found that 45 of the charts had unsupported diagnoses.

For example, the report found that PacifiCare -- a subsidiary of UnitedHealth Group -- was overpaid for patients who received treatment for cancer or serious bloodstream infections, even though the medical records did not show such ailments.

In two cases, PacifiCare submitted codes for a genetic disorder related to an abnormal brain function and prostate cancer, but medical records showed that one patient had a fever and cough, while the other had a shoulder suture removal.

In the report, the inspector general directed the insurer to repay CMS a total of $224,388 for the 45 charts with unsupported diagnoses.

Response From UnitedHealth

In a statement, UnitedHealth disputed the OIG's report and argued that an analysis of 100 cases should not be generalized to reflect all other claims.