UnitedHealthcare Texas MA audit recommends diagnosis-code refunds
Oct 11, 2026 edition · GC-2026-0190 · Published 2026-10-11 · Version 4 · Final
An OIG audit estimates at least $24.4 million in UnitedHealthcare Benefits of Texas MA overpayments for selected high-risk diagnoses in 2020–2021. United disputed some findings and asked OIG to withdraw the recommendations. This is an audit estimate, rather than a settlement or established recovery.
What happened
OIG’s audit of UnitedHealthcare Benefits of Texas, Inc., contract H0609, examined selected diagnosis codes at high risk of miscoding in Medicare Advantage risk adjustment. Issued September 23 and posted September 28, report A-07-24-01215 found that records did not support selected diagnoses for 172 of 230 sampled enrollee-years. The sample produced $622,927 in identified overpayments; OIG extrapolated at least $24.4 million for 2020 and 2021. An enrollee-year is the sampling unit here, not a count of unique patients.
MA payments depend in part on diagnoses submitted to CMS, so unsupported codes can affect payment even when the underlying encounter occurred. OIG said United’s prevention, detection and correction controls could improve and made four recommendations, including a refund of the estimated amount. United disagreed with some findings and requested withdrawal of all recommendations. The selected high-risk sample does not establish that all diagnoses submitted by the plan were unsupported. The findings warrant review of documentation and correction controls while preserving the difference between an audit recommendation and an adjudicated debt or completed recovery.
Scope and timing
- Authority status
- Final
- Applicability
- Operationally relevant
- Audience
- Health systems, Provider networks
- Jurisdiction
- Federal
Why it matters
The action identifies a control failure relevant to provider, payer or vendor oversight. Its procedural status must be kept separate from any allegation.
Recommended action
Reconcile risk-adjustment diagnosis support and evaluate refund exposure with Legal before treating an audit estimate as established liability.
Case details
- agencies
- HHS OIG, CMS
- entities
- UnitedHealthcare Benefits of Texas, Inc. (Contract H0609)
- action Type
- Audit
- event Date
- 2026-09-23
- 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 2026-10-11
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