oig.hhs.gov

Medicare Advantage Compliance Audit of Specific Diagnosis Codes That UnitedHealthcare Benefits of Texas, Inc. (Contract H0609), Submitted to CMS

Under the Medicare Advantage (MA) program, CMS makes monthly payments to MA organizations based in part on the health status of the enrollees being covered. To determine the health status of enrollees ...
oig.hhs.gov

Medicaid Managed Care: CMS’s Accuracy Check Process For State-Submitted Medical Loss Ratio Data Has Limitations

Medical loss ratios (MLRs) are an important part of Medicaid managed care fiscal oversight. An MLR shows whether a managed care plan spent most of its Medicaid funds on medical costs. Specifically, an ...
oig.hhs.gov

New York Made Unallowable Managed Care Capitation Payments on Behalf of Incarcerated Medicaid Enrollees

New York pays managed care organizations to make services available to eligible Medicaid enrollees in return for a monthly fixed payment (capitation payment) for each enrollee. Previous audits found ...
oig.hhs.gov

Methodist Hospital Received at Least $12.4 Million in Medicare Overpayments

For calendar year 2021, Medicare paid hospitals $182 billion, which represents 46 percent of all fee-for-service payments; accordingly, it is important that hospital payments comply with requirements.
oig.hhs.gov

Twelve Individuals Charged in $10M Home Daycare Fraud Schemes

Twelve individuals are facing federal fraud charges after an investigation revealed that more than $10 million intended to help low-income families pay for childcare was instead funneled to bogus ...
oig.hhs.gov

Medicare Advantage Compliance Audit of Specific Diagnosis Codes That HumanaChoice (Contract H5216) Submitted to CMS

Under the Medicare Advantage (MA) program, CMS makes monthly payments to MA organizations based in part on the health status of enrollees being covered. To determine the health status of enrollees, ...