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DOJ investigating Humana's Medicare Advantage billing process

An annual SEC filing sheds light on the government's concern with upcoding risk scores

The Department of Justice (DOJ) has requested information from Humana regarding risk adjustments assigned to Medicare Advantage beneficiaries, according to an annual report the insurance company filed to the Securities and Exchange Commission (SEC). 

The report offers a brief inside look at how the feds are following up on criticisms levied against the Louisville, Kentucky-based insurance giant, and Medicare Advantage plans in general, in an investigative series recently published by the Center for Public Integrity.  

The issue was reinvigorated last week following charges against a South Florida physician who allegedly overcharged Medicare Advantage plans. The physician was charged on eight counts of healthcare fraud involving upcoded risk scores associated with Medicare Advantage patients, which led to $2.1 million in allegedly fraudulent payments. Humana provided the Medicare Advantage plan, but was not implicated in the charges.

However, the SEC filing indicates that the DOJ has requested information concerning the company's risk adjustment practices and compliance procedures. The report sites two previous whistleblower cases involving Humana that have been dismissed, but federal investigators are looking for information pertaining to Humana's "oversight and submission of risk adjustment data" assigned by providers within the Medicare Advantage network, "business and compliance practices related to risk adjustment data," medical record reviews associated with compliance efforts, the use health and well-being assessments and fraud detection efforts.

Humana indicates that it "continues to cooperate with and voluntarily respond to the information requests."

"I'll watch this investigation to see if it might result in ways to improve risk adjustment policy, either through [Centers for Medicare & Medicaid Services] action on its own or legislation if necessary," Senate Judiciary Committee chairman Chuck Grassley (R-Iowa) told CPI. "If the policy drives overbilling, it should be fixed."

This is not the first interaction that Humana has faced with federal investigators. Last year, CPI reported that Humana was involved in multiple federal investigations into Medicare Advantage overpayments, as well as multiple whistleblower lawsuits. Medicare Advantage plans have also been the target of scrutiny over the past several years, particularly when it comes to risk scores. Some estimates say that these errors cost the government $32 billion between 2008 and 2010, most of which is never recovered.

Last week, CMS announced a proposal to cut Medicare Advantage rates by 0.95 percent in 2016, although risk-scoring adjustments will give insurers a 1.05 percent increase. However, insurers expect much steeper funding cuts as a result of the proposed changes.

For more:
- here's the SEC filing
- read the latest Center for Public Integrity article

Related Articles:
Florida fraud case highlights concerns regarding Medicare Advantage upcoding
Feds overlook billions in Medicare Advantage overpayments
Medicare Advantage rate cut would reduce payer funding