A federal judicial master’s critique of CMS’ audit case against a health insurer, “A mere possibility of an overpayment is not enough for the government to carry its burden.”
The problem with the government’s allegations is that the government knew of the very chart review practices which it now claims United prevented it from learning, and thus the government cannot have been duped into relying on any action or inaction by United in determining whether it had been the victim of overpayments,” Segal wrote. Segal noted CMS audits of UnitedHealth’s Medicare Advantage plans had found that about 89% of billing codes were supported by patient medical records. The audit findings “undercut” the government’s claim that the company engaged in widespread overbilling.
In Sum, the special master, who was appointed by U.S. District Judge Fernando Olguin, concluded the government’s case “depends entirely on speculation and assumptions about what the codes found by the United coders actually mean.” https://kffhealthnews.org/news/article/unitedhealth-special-master-ruling-medicare-advantage-overpayments/
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