Author: Christine Geiger, MA, RHIA, CCS, CRC | October 26, 2026
If you have spent any time watching TV lately, you surely have been bombarded with commercials about Medicare Advantage (MA) plans. Medicare open enrollment ends on Dec. 7, so we will be seeing them for a few more weeks. I find myself listening a little bit closer each year as I creep toward that eligibility age, but I will be glad when Dec. 8 rolls around. For our Focus on Fraud this week, we will be looking at the MA Compliance Audit performed by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), centering on of UnitedHealthcare Benefits of Texas, Inc.
Published September 2026, this audit is one in a series where the accuracy of diagnosis codes MA organizations submit to the Centers for Medicare & Medicaid Services (CMS) is reviewed. This particular audit focused on 11 high-risk groups of diagnosis codes; these were identified as acute stroke, acute myocardial infarction, embolism, lung cancer, breast cancer, colon cancer, prostate cancer, ovarian cancer, sepsis, pressure ulcer, and diagnoses that are potentially mis-keyed or entered or submitted incorrectly.
As coders, when we hear that list, we easily can conceive of some of the potential challenges associated with them. It might be due to the supporting documentation, or lack thereof. Maybe the coders are unclear on cancer coding guidelines…and then there is sepsis. The bottom line is that as coders, we know the potential for inaccuracy with these diagnosis code groups.
The audit included a sample of 230 claims wherein program enrollees had a reported high-risk diagnosis in service years 2019 and 2020. UnitedHealthcare then would have received risk-adjusted payments for payment years 2020 and 2021. A total of 200 claims of this sample were related to the high-risk diagnosis groups, and 30 of the sample were those potentially mis-keyed diagnoses.
The good news is that for 58 claims of the sample of 230, medical record documentation supported and validated the reported Hierarchical Condition Category (HCC). For the remaining 172, however, either the medical records could not be located, or the documentation did not support the reported HCC.
The audit sample showed a total of $622,927 in overpayments because of the unvalidated HCCs. While that is a large number, remember, this was just the sample. Based on those results, the OIG estimated that the total overpayment based on unvalidated HCCs for 2020 and 2021 was $24,465,369. UnitedHealthcare reportedly does disagree with some of the findings, and I encourage you and your staff to review the full audit report. I have included the link to the report in my article this week.
For a further breakdown on the findings by diagnosis, the OIG notes that acute stroke codes were incorrectly submitted on 19 of 20 sampled. For the acute myocardial infarction, 17 of 20 were submitted incorrectly. Embolism codes were incorrectly submitted on 15 of 20.
On the cancer types, as a combined number, only 9 of 100 sampled were submitted correctly. Sepsis and pressure ulcer scored a bit better, with 7 of 20 incorrectly submitted sepsis codes and 5 of 20 incorrectly submitted codes for pressure ulcer.
The potential mis-keyed diagnoses accounted for 18 incorrectly submitted codes out of the sample of 30.
Whether you code MA accounts or not, I would encourage you to review the findings and identify potential problem areas, especially within the identified high-risk diagnosis groups, for which coders may need a guideline refresher or additional education.
This list is a great place to start to either perform a focused review on your team or prepare some learning opportunities.
This article was originally published on RACmonitor.
