A decade ago, there was a plan to crack down on Medicare Advantage health insurers for overcharging the government by billions of dollars but it was mysteriously dropped, court documents reveal.
The draft regulation proposed in January 2014 would have required health plans to identify overpayments by CMS and refund them to the government when reviewing patient records.
However, in May 2014, the plan was abandoned without a clear explanation, with agency officials citing industry pressure as a significant factor.
This decision is now central to a multi-billion dollar civil fraud case against UnitedHealth Group, accusing them of cheating Medicare out of more than $2 billion by manipulating patient records.
The case highlights the contentious relationship between Medicare and health insurers, particularly in the lucrative Medicare Advantage market.
Despite the ongoing legal battle, UnitedHealth Group maintains its innocence, arguing that they should not be penalized for a rule that CMS considered but never adopted.
This month, thousands of pages of depositions and records related to the case were made public, shedding light on CMS’s struggle to regulate the industry.
The case reveals a complex web of allegations, with whistleblowers claiming that health plans inflated costs through obscure medical coding practices.
Missed Diagnoses
Medicare Advantage plans’ explosive growth has raised concerns about fraudulent billing practices, including the misuse of chart reviews to boost profits at the expense of taxpayers.
In a controversial move, CMS abandoned a regulation that aimed to curb these practices in response to industry backlash, showcasing the influence of health plans over federal regulations.
Experts criticize CMS for prioritizing industry interests over taxpayer savings, highlighting the need for stronger oversight in the Medicare Advantage program.
Invalid Codes
The ongoing legal battle between the Justice Department and UnitedHealth Group exposes systematic abuse of Medicare billing codes, with allegations of over $7 billion in fraudulent payments.
The case underscores the challenges of regulating a complex and profitable sector like Medicare Advantage, where financial incentives can lead to unethical practices.
The revelations from the case have sparked debates about the integrity of the healthcare system and the need for tighter controls to protect public funds.
