News: CMS responds to industry pressure over overbilling regulations, records show
Newly released court documents reveal that CMS backed down on drafting Medicare Advantage overbilling regulations after a massive outcry from the healthcare industry, KFF News reported.
In January 2014, CMS published a draft regulation that would’ve required insurers to reimburse CMS overpayments identified on patient medical records; however, in May 2014, CMS dropped the idea “without any public explanation,” KFF said.
According to former CMS officials quoted in KFF, the reason for throwing out the draft was due to a concerted lobbying effort on behalf of the biggest leaders in the industry. For instance, the then director of CMS’ Medicare plan payment group argued in 2022 that the overbilling effort was discarded because of “stakeholder concern and pushback,” with another CMS official describing the industry’s reaction as an “uproar.”
The draft regulation is currently at the heart of a legal dispute between the Department of Justice (DOJ) and the UnitedHealth Group. According to KFF, the DOJ alleges that, between 2009 and 2016, “the giant health insurer cheated Medicare out of more than $2 billion by reviewing patients’ records to find additional diagnoses, adding revenue while ignoring overcharges that might reduce bills.”
UnitedHealth alleges that it was not legally required to reimburse the federal government because of a lack of overbilling legislation.
Editor’s note: To read the KFF coverage, click here.