One Hundred Eighty Million From Codes the Chart Did Not Support

The HHS Office of Inspector General just posted audits of two Medicare Advantage plans run by the biggest names in the business. HumanaChoice and UnitedHealthcare of Wisconsin. The charge is simple: diagnosis codes went to CMS that the medical records did not back up. Risk scores went up. Capitation followed.

For HumanaChoice, one hundred seventy-eight of two hundred twenty sampled enrollee-years failed. Extrapolated, that is at least one hundred thirty point nine million dollars in overpayments for twenty twenty and twenty twenty-one. For UnitedHealthcare of Wisconsin, one hundred eighty-three of two hundred fifty failed. Another forty-six point nine million. Add them and you get almost one hundred eighty million from two contracts, two years, and a payment model that pays more when the code list looks sicker.

Source: oig.hhs.gov/reports/all/2026/medicare-advantage-compliance-audit-of-specific-diagnosis-codes-that-humanachoice-contract-h5216-submitted-to-cms/ and oig.hhs.gov/reports/all/2026/medicare-advantage-compliance-audit-of-specific-diagnosis-codes-that-unitedhealthcare-of-wisconsin-inc-contract-h5253-submitted-to-cms/

I am not shocked. When the check gets bigger every time the chart gets longer, the chart gets longer. Both plans say the methodology is flawed and they do not plan to send the money back. That is their right to argue. It does not change the incentive.

I am not anti-insurance. Keep a policy for the wreck. I am anti a system that turns a diagnosis into a billing asset and then acts surprised when the codes outrun the care. We take care of patients for a flat monthly fee. No claim. No risk score. No bonus for a sicker-looking list. The number on the door is the number you pay.

One hundred eighty million is not a rounding error. It is what happens when payment follows the code instead of the visit.