Federal auditors at the Department of Health and Human Services say UnitedHealthcare Benefits of Texas, Inc. received at least $24.4 million in Medicare Advantage overpayments for 2020 and 2021. The figure is an estimate built from a sample of enrollee records, and the insurer has pushed back, asking the auditors to withdraw every one of their recommendations.
The finding comes from the HHS Office of Inspector General, which issued report A-07-24-01215 on Sept. 23 and posted it Sept. 28. It covers contract H0609. OIG recommends that the plan refund $24,465,369 to the federal government.
What did the auditors actually find?
OIG reviewed diagnosis codes that the plan sent to the Centers for Medicare & Medicaid Services, which uses them to adjust what it pays Medicare Advantage insurers each month. Payments rise when enrollees carry more serious diagnoses, so a code that the medical record does not support can mean the insurer was paid more than it should have been.
The auditors examined a sample of 230 enrollee-years. Medical records failed to support the selected diagnosis codes for 172 of them, according to the report. In the sample alone, the unsupported codes produced $622,927 in overpayments. OIG concluded that most of the selected high-risk diagnosis codes the plan submitted did not comply with federal requirements.
Does any of this land on a member’s own costs?
Nothing in OIG’s summary says members owe money or that premiums, copays or benefits change because of the audit. The overpayments are payments from the federal government to the plan, and the proposed refund runs the same direction, from the plan back to the government. The dispute is between the insurer, the auditors and CMS.
For a member of a Medicare Advantage plan in Texas, the practical question is whether the plan’s own billing to the member is right. A diagnosis-coding problem would not show up on a member’s statement, but wrong charges and unexpected balances do, and those can be challenged on a deadline.
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Is $24.4 million an exact count?
No. OIG says the $24.4 million is an estimate extended from the sample to all of the plan’s payments for the two years, and it phrases the result as “at least” that amount. The report’s highlights say the estimate comes from the sample results. The auditors did not tally $24.4 million claim by claim.
The word the auditors use is “received,” in the sense of overpayments, and the remedy they propose is a refund. They do not say the money was stolen, and the report does not describe a fraud finding. Nor has any money been returned: OIG lists all four recommendations as open and unimplemented.
That distinction affects how the number should be read. A sample-based estimate carries uncertainty that a counted total does not, and the plan has the right to dispute the method and the findings, which it has done.
What does UnitedHealthcare say?
According to the report page, the insurer disagreed with some of OIG’s findings and asked the office to withdraw all of its recommendations. The page does not detail the plan’s arguments in the summary, and the auditors kept their recommendations in place.
The recommendations go to CMS, which decides what the plan must repay. OIG’s listing shows the recommendations as open, with the next update on their status expected April 15, 2027. Until CMS acts, the $24.4 million remains an auditor’s estimate rather than a bill.
The four recommendations go beyond the headline refund. OIG asks that the plan check the 26 enrollee-years it did not review in one high-risk group, refund anything those records fail to support, look for similar problems in the years after the audit period, and strengthen its procedures for high-risk diagnosis codes.
Where does a member report a billing problem?
Medicare directs beneficiaries who suspect fraud or abuse to its fraud and abuse reporting page. A member who sees a charge for a service never received, or a balance that does not match the plan’s explanation of benefits, can start there and should keep the statements.
The audit itself is a reminder of how Medicare Advantage is paid. CMS pays plans a monthly amount partly based on enrollees’ health status, and it relies on the plans to collect diagnosis codes from providers and submit them. OIG says some diagnoses are at higher risk of being miscoded, which is why it has run a series of these audits on high-risk codes. The report highlights lay out that background.
This audit covers one plan and two years. It does not speak for other UnitedHealthcare plans or other insurers, and OIG’s estimate applies only to contract H0609.
Is your Medicare plan billing you correctly?
A plan’s audit fight is out of any member’s hands, but the member’s own statements are not. Errors there rarely announce themselves, and an appeal has to be filed inside the window or the charge stands.
The Medicare Money Bundle puts all 8 Medicare guides in one download, with large print, for $8. Among them is Medicare Billing Errors: read your statements, fix wrong charges, appeal in time. The guide walks through reading a statement line by line before deciding whether a charge is wrong.
Check your own Medicare statements with The Medicare Money Bundle →
This article was produced with AI assistance and edited for accuracy against the sources linked above.
Warren Cohen is a finance writer based in Phoenix, Arizona, covering personal finance topics including credit, banking, and beginner investing. He earned his degree in business administration from Arizona State University and began his career working in consumer finance, where he gained direct experience with lending and credit systems. He now writes for personal finance websites and fintech platforms, focusing on clear, practical content that helps readers make informed financial decisions.
