UnitedHealthcare Texas MA audit recommends diagnosis-code refunds
Oct 4, 2026 edition · GC-2026-0190 · Published 2026-10-04 · Version 2 · Final
OIG estimated at least $24.4 million in UnitedHealthcare Texas MA overpayments from selected diagnosis codes; United disagreed with some findings and requested withdrawal of recommendations.
What happened
OIG's audit of UnitedHealthcare Benefits of Texas, Inc., contract H0609, was issued September 23 and posted September 28, 2026. It examined selected high-risk diagnoses submitted for Medicare Advantage risk adjustment. Medical records did not support diagnoses in 172 of 230 sampled enrollee-years, producing $622,927 in sampled overpayments. From those sample results, OIG estimated at least $24.4 million in overpayments for 2020 and 2021. The estimate is distinct from the sample amount and does not establish that every UnitedHealthcare diagnosis was unsupported.
OIG recommended a $24.4 million refund among four recommendations and said policies and procedures to prevent, detect and correct noncompliance could improve. United disagreed with some findings and requested withdrawal of all recommendations. These are audit findings and recommendations, not a court judgment or negotiated settlement, and the release does not prove that the estimated amount was repaid. A plan's operational review should connect submitted diagnoses to actual medical-record support, evaluate the selected risk areas and assess any resulting refund question under applicable law rather than treating an audit estimate as an adjudicated debt.
Scope and timing
- Authority status
- Final
- Applicability
- Operationally relevant
- Audience
- Health systems, Provider networks
- Jurisdiction
- Federal
Why it matters
Risk-adjustment controls need medical-record support and a defensible response to audit findings, including disagreement and extrapolation issues.
Recommended action
Review diagnosis support and correction workflows in relevant risk areas. Quantify supported exceptions and obtain Legal's refund analysis, distinguishing sample errors, estimated exposure and final determinations.
Case details
- agencies
- HHS OIG, CMS
- entities
- UnitedHealthcare Benefits of Texas, Inc. (Contract H0609)
- action Type
- Audit
- event Date
- 2026-09-28
- alleged Conduct
- OIG found unsupported diagnoses in 172 of 230 sampled enrollee-years and recommended an estimated $24.4 million refund for 2020 and 2021. UnitedHealthcare disagreed. Recommendations are not an adjudicated settlement.
- resolution
- OIG audit findings and recommendations, not a court judgment or settlement.
Operational lessons
- Reconcile risk-adjustment diagnosis support and evaluate refund exposure with Legal before treating an audit estimate as established liability.
Sources
- UnitedHealthcare Texas MA audit recommends diagnosis-code refundsOfficial · HHS OIG · 2026-09-28 · Source review 2026-10-04
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