UnitedHealth was handed a major setback Tuesday, June 21st, when the US Supreme Court declined to hear its lawsuit over the Medicare Advantage overpayment rule. The Centers for Medicare and Medicaid Services (CMS) established the overpayments rule in 2014, which mandates that MA plans must return Medicare overpayments. In addition, diagnoses submitted by MA plans are deemed overpayments if they lack supporting documentation.
According to Robert King, “A lower court in 2018 fully vacated the overpayment rule, arguing it violated Medicare’s statute for “actuarial equivalence” with traditional Medicare. Normally, payments for both fee-for-service Medicare and MA are set annually based on costs from unaudited Medicare data, but the rule threw that out of balance, because the MA payments were set based on audited patient records. CMS appealed the ruling in 2018, and, in August 2021, the U.S. Court of Appeals for the District of Columbia sided with the agency against UnitedHealth.”
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(Source: Fierce Healthcare, June 22nd, 2022)