News: OIG audit calls for Humana, CVS to repay millions in MA overpayments

The Department of Health and Human Services Office of Inspector General (OIG) is requesting a $6.8 million refund from Humana and a $4.2 million refund from CVS for Medicare Advantage (MA) overpayments, according to two audit reports recently published by the OIG. These reports come amidst significant scrutiny over potential overpayments in the MA program by CMS and Congress, Fierce Healthcare reported.

Based on a random sample of 240 unique enrollee years, the OIG estimates that Humana received at least $13.1 million in overpayments in 2017 and 2018. Similarly, from a random sample of 269 unique enrollee years at HealthAssurance Pennsylvania (a subsidiary of CVS Health's Aetna), the insurer received $4.2 million in overpayments in 2018 and 2019.

The OIG said that federal regulations did limit using risk adjustment data validation (RADV) audits for recovery purposes before 2018, which would explain the discrepancy between the overpayment estimate and recommended refund for Humana.  

“In addition to the refunds, OIG is urging the payers to identify further noncompliance outside of the audit period while also continuing to monitor compliance and take steps to correct any issues,” Fierce Healthcare reported.

In response, both insurers have issued disagreements with some of the findings made by the OIG, and neither concurred with the recommendations.

Editor’s note: To read Fierce Healthcare’s coverage of this story, click here. To read the OIG audit report for Humana, click here. To read the OIG audit report for CVS, click here.