Nearly three-quarters of selected enrollee-years failed review
The HHS inspector general found that medical records did not support diagnosis codes in 172 of 230 sampled enrollee-years submitted by UnitedHealthcare Benefits of Texas for Medicare Advantage risk adjustment. That is 74.8% of the selected sample.
Those unsupported codes resulted in $622,927 in sampled overpayments. OIG used its sample to estimate at least $24.4 million in overpayments for 2020 and 2021.
| Measure | Result |
|---|---|
| Sampled enrollee-years | 230 |
| Unsupported diagnosis-code records | 172 (74.8%) |
| Sample overpayments | $622,927 |
| Estimated minimum overpayments | $24.4 million |
Why the codes affect payment
Medicare Advantage payments are adjusted partly for enrollees' health status. Plans collect diagnosis codes from providers and submit them to CMS; unsupported higher-risk diagnoses can increase federal payments.
The audit focused on codes identified as high risk, not a random review of every diagnosis or every UnitedHealthcare contract. The 74.8% sample share therefore must not be described as a companywide error rate.
United disputed the audit
OIG made four recommendations, including refunding the estimated $24.4 million and improving controls. United disagreed with some findings and asked the inspector general to withdraw all recommendations.
An audit recommendation is not the same as a final adjudicated debt. CMS processes, appeals and later documentation can affect collection. The published disagreement is material counterevidence and belongs beside the estimate.
Method and limits
What’s the Scoop With Broach calculated the selected-file share and kept sampled dollars separate from the OIG's statistically estimated minimum. The factual findings and estimate are attributed to the inspector general.
The report concerns a Texas contract and 2020–2021 submissions. It does not establish that every code, clinician, enrollee or UnitedHealthcare plan had the same problem.
Sources and further reading
HHS OIG UnitedHealthcare Benefits of Texas audit summary, September 2026 ↗