Last year, a report from the Office of Inspector General at the U.S. Department of Health and Human Services (HHS) found UnitedHealth Group stood out from its peers — but wasn’t alone — in using questionable diagnosis data to boost MA risk adjustment payments by billions of dollars.
In September 2023, the Connecticut-based health insurance giant Cigna agreed to pay $172.2 million to resolve allegations that it violated federal law by submitting and failing to withdraw “inaccurate and untruthful” diagnosis codes for its MA enrollees to increase its payments from the federal government.
Calls for change within MA came just this week, as subcommittees on Health and Oversight at the House Ways and Means Committee held a joint hearing to examine lessons learned after more than two decades of the program.
MA, which was launched in the 1990s and expanded in the mid-2000s with bipartisan legislation for the Medicare Part D drug benefit, now covers a majority of Medicare beneficiaries. Some lawmakers have zeroed in on the program’s risk adjustment funding, in particular.
“The most effective step the [Trump] Administration can take in cutting waste, fraud, and abuse in federal health care programs is by reining in the wasteful practices of corporate health insurers in the MA program,” Massachusetts Sen. Elizabeth Warren wrote in a March letter co-signed by Minnesota Sen. Tina Smith and six other Democratic senators.
The letter did not name UnitedHealth, but the company is the nation’s largest MA insurer. Senators asked HHS Secretary Robert F. Kennedy Jr. to further crack down on alleged “upcoding,” where insurers are thought to manipulate diagnosis data to make patients look sicker and gain more federal dollars.
