UnitedHealthcare’s Medicare Advantage business in Texas received an estimated $24.4 million in overpayments during 2020 and 2021 tied to diagnoses not supported by medical records, confirming the UnitedHealthcare Texas $24.4 million overpayments finding detailed in an HHS Office of Inspector General audit report published Sept. 28.
The Contract Behind This UnitedHealthcare Texas $24.4 Million Overpayments Finding
The audit examined a UnitedHealthcare MA plan that covered about 339,000 enrollees in Texas as of December 2021 and received roughly $8.8 billion from CMS across the 2020 and 2021 payment years. Of 230 sampled cases, 172 lacked medical record support for the submitted diagnosis codes, a 75% error rate.
How OIG Extrapolated This Estimate
The OIG found $622,927 in overpayments from the sampled cases in Texas and estimated the total at $24.4 million after extrapolating across the broader population. This extrapolation from a relatively small sample to the full contract’s population is a standard OIG audit methodology, though one UnitedHealthcare has separately challenged as unreliable.
Why This UnitedHealthcare Texas $24.4 Million Overpayments Audit Follows a Familiar Pattern
The report follows an OIG audit released a week prior that estimated UnitedHealthcare’s Wisconsin MA business received $46.9 million in overpayments over the same two years. The Texas plan’s 75% error rate closely mirrors the Wisconsin plan’s 73% error rate, suggesting a consistent, company-wide pattern rather than an issue isolated to a single state or contract.
The Specific Diagnosis Categories Driving These Errors
The errors followed the same pattern seen in Wisconsin, with patients coded as having active conditions when their records showed only a history of them. Acute stroke and prostate cancer each had 19 of 20 sampled cases in error, while lung, breast, colon and ovarian cancer each had 18 of 20. UnitedHealthcare also could not locate medical records for three of the sampled cases.
The Data Filter Gap Within This UnitedHealthcare Texas $24.4 Million Overpayments Audit
The OIG noted that UnitedHealthcare had a data filter designed to block unsupported acute stroke codes, but it applied only to codes from in-home health visits and chart reviews, not to codes submitted directly by providers. This gap suggests UnitedHealthcare’s internal compliance safeguards were incomplete, catching errors from one submission channel while leaving another, provider-submitted codes, unchecked.
Why This Distinction Matters for Future Compliance
Identifying this specific coverage gap in UnitedHealthcare’s own filtering system gives the insurer a concrete, actionable finding to address going forward, distinct from the broader question of whether OIG’s overall audit methodology and extrapolation approach are themselves valid.
UnitedHealthcare’s Response to This Texas Overpayments Audit
UnitedHealthcare contested 25 of the cases identified as errors and asked the OIG to withdraw all four of its recommendations. The OIG reversed nine of the contested cases, reducing the original error count from 181 to 172. The insurer argued the audit ignored potential underpayments, relied on samples too small for reliable extrapolation, and should have applied a fee-for-service adjuster, all arguments OIG rejected.
UnitedHealthcare’s Broader Statement on the Audit Process
“While we welcome government reviews of our Medicare Advantage program, we disagree with the current approach to validating data,” a UnitedHealthcare spokesperson said. “The flawed methodology in this report from the Office of the Inspector General is further evidence that modernization is needed, and we remain committed to working with both CMS and the OIG to improve the program and their audit processes.”
What This UnitedHealthcare Texas $24.4 Million Overpayments Finding Means Going Forward
The OIG’s recommendations are not final decisions, and CMS ultimately decides whether to pursue recoupment, with insurers also retaining the right to appeal. Given that OIG already reversed nine of UnitedHealthcare’s 25 contested cases in this specific audit, the final recovery amount CMS pursues may differ from the initial $24.4 million estimate once any further appeals or reviews are resolved.
What to Watch Going Forward
As CMS reviews this Texas finding alongside the recent Wisconsin audit, industry observers will likely watch whether additional state-specific UnitedHealthcare MA audits follow the same consistent pattern of diagnosis-code errors, particularly around acute stroke and cancer-related codes. Given UnitedHealthcare’s continued push for changes to OIG’s audit methodology, this UnitedHealthcare Texas $24.4 million overpayments case may become part of a broader dispute over how CMS and OIG validate Medicare Advantage risk adjustment data across the company’s national contract portfolio.
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