https://www.healthcaredive.com/news/hhs-oig-audit-humana-unitedhealthcare-medicare-advantage-upcoding-overpayments/830632/
3 replies (most recent on top)
Stealing is stealing!
Not only did the up-coding allow for higher government reimbursements but it also raised our elderly Medicare Members who are in a fixed income to have higher OOP out of pocket expenses.
It would be no different than if the CEO himself shoved a little old lady down and ran off with her purse.
I’m not sure I understand why Humana would do such a thing. Don’t they know that is dishonest and could even be construed as outright theft?!
The Below is all public record, accessible by anyone with basic internet browser search capabilities.
Humana is facing intensive regulatory scrutiny and recent federal audits for "upcoding" in its Medicare Advantage plans, which involves allegedly exaggerating the sickness of its enrollees to secure higher government reimbursements.
The latest development occurred in September 2026, when a U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) compliance audit determined that Humana's HumanaChoiceplan received at least $130.9 million in overpayments for the 2020 and 2021 payment years.
Key Findings from the September 2026 Audit
- High Error Rate: Auditors reviewed a random sample of 220 enrollees and discovered that 178 cases (81%) lacked medical record documentation to support the diagnosis codes Humana submitted to the Centers for Medicare & Medicaid Services (CMS).
- Active vs. Past Conditions: The most prominent issue involved providers coding patients for active, acute conditions when their medical files showed they only had a past history of those conditions (such as treating a historical stroke survivor as having a current, acute stroke).
- Targeted Diseases: The errors were most heavily concentrated in high-risk categories like acute stroke, acute myocardial infarction (heart attack), and various cancers (br---t, colon, lung, and ovarian).
Wider Scrutiny & Humana's Defenses
This is part of a broader crackdown on Medicare Advantage upcoding across the insurance industry. Aside from this direct audit, The DOJ recently announced a $541.5 million settlement with Florida-based primary care provider The Villages Health for similar upcoding behaviors spanning 2020 to 2024—a provider that Humana acquired late last year.
Humana's Response: Humana has strongly disputed the OIG's audit methodology and rejected recommendations to return the estimated $131 million. The company argues that the audit is structurally biased because it checks for unsupported codes but fails to credit insurers for instances where a doctor forgot to submit a valid diagnosis code. Humana has also aggressively fought the government in court, successfully challenging parts of CMS's strict Risk Adjustment Data Validation (RADV) audit rules.