Medicare Advantage Compliance Audit of Specific Diagnosis Codes That UnitedHealthcare of Wisconsin, Inc. (Contract H5253) Submitted to CMS

Report Materials

• Full Report (PDF, 3.1 MB)
• Report Highlights (PDF, 343.8 KB)

Why OIG Did This Audit

• Under the Medicare Advantage (MA) program, CMS makes monthly payments to MA organizations based in part on the health status of the enrollees being covered.
• To determine the health status of enrollees, CMS relies on MA organizations to collect diagnosis codes from their providers and submit these codes to CMS. Some diagnoses are at higher risk for being miscoded, which may result in overpayments from CMS.
• This audit of UnitedHealthcare of Wisconsin, Inc. (United), is part of a series of audits of high-risk diagnosis codes that MA organizations submitted to CMS for use in its risk adjustment program.

What OIG Found

Most of the selected diagnosis codes that United submitted to CMS for use in CMS's risk adjustment program did not comply with Federal requirements.

• For 183 of the 250 sampled enrollee-years, medical records did not support the diagnosis codes and resulted in $722,280 in overpayments.
• On the basis of our sample results, we estimated that United received at least $46.9 million in overpayments for 2020 and 2021.

As demonstrated by the errors found in our sample, United's policies and procedures to prevent, detect, and correct noncompliance with CMS's program requirements could be improved.

What OIG Recommends

We made four recommendations, including that United refund to the Federal Government the $46.9 million in estimated overpayments. The full recommendations are in the report.

United disagreed with some of our findings and requested that we withdraw all our recommendations.