Carriers & the market
Federal Audit Estimates HumanaChoice Received at Least 130.9 Million Dollars in Medicare Advantage Overpayments
For 178 of 220 enrollee-years examined, medical records did not support the diagnosis codes HumanaChoice submitted to CMS. The plan disputed every recommendation.
By the Goodsurance editorial teamSeptember 16, 2026
Federal auditors have estimated that HumanaChoice received at least 130.9 million dollars in Medicare Advantage overpayments for policy years 2020 and 2021, according to a compliance audit released September 10 by the Department of Health and Human Services Office of Inspector General.
The OIG reviewed a sample of 220 enrollee-year records and found that 178, or about 81 percent, lacked adequate medical-record support for the diagnosis codes HumanaChoice submitted to CMS. Those codes feed into a risk-adjustment formula that sets monthly payments to Medicare Advantage organizations. Plans that submit higher-risk diagnoses receive larger payments; when those diagnoses are not backed by records, payments are higher than warranted.
A federal audit found HumanaChoice may owe at least 130.9 million dollars for Medicare Advantage diagnosis codes its medical records did not support.
Unsupported codes in the sample produced 669,237 dollars in overpayments. OIG projected that figure across the full population of enrollees in the examined risk groups and arrived at an estimated minimum of 130.9 million dollars in excess payments.
The OIG recommended that Humana, Inc., refund the 130.9 million dollars to the federal government. Auditors also recommended that the company separately review 212 enrollee-years not included in the sample from one high-risk group and return any additional overpayments that review identifies.
Humana, Inc., disagreed with some audit findings and with all of the recommendations. The audit is part of a continuing OIG series examining high-risk diagnosis codes submitted by Medicare Advantage plans; earlier reports in the same series covered Gateway Health Plan, Priority Health, and other carriers.
In plain words
Medicare's health care watchdog reviewed one Humana plan called HumanaChoice. It found that for most of the patient records it checked, the medical codes the plan sent to the government were not backed up by what was in those records. Plans use those codes to get paid more money. The watchdog estimates this added up to at least 130.9 million dollars in extra payments for 2020 and 2021. It said Humana should pay that money back. Humana said it disagrees.
Understand the basics first
Source: OIG HHS
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