Humana sues US govt over new rule

Regulation changes how Medicare audits

Louisville-based insurance company Humana is suing the U.S. government following the elimination of a rule that will allow Medicare to claw back payments to insurance companies, a company spokesperson confirmed Friday.

The federal lawsuit, filed in the Northern District of Texas, challenges the new rule finalized this year by the U.S. Department of Health and Human Services and the Centers for Medicare and Medicaid Services that determines whether private Medicare Advantage plans covering patients over 65 were overpaid.

In its filing, the company claimed the decision to change the rule was not justified, the government did not allow people to comment before making the rule final and it is being applied retroactively instead of for future instances as required by law.

“Our decision to take this legal action came only after careful consideration. We believe this step is in the best interest of Humana members and Medicare Advantage,” Humana spokesperson Mark Taylor said in a statement. “This parity is foundational to the Medicare Advantage program and the high-quality benefits and low premiums that Humana members and seniors choosing Medicare Advantage depend on.”

The Risk Adjustment Data Validation program policies were finalized on Jan. 30 and will “protect Medicare, strengthen Medicare Advantage, and hold insurers accountable,” according to a release from the U.S. Department of Health and Human Services.

The program oversees payments made to insurance companies in “instances where medical diagnoses submitted for payment were not supported in the beneficiary’s medical record,” the government department stated.

Under the new rule, the federal government is anticipated to claw back more than $4 billion from insurance companies over the next decade.

CJ FILE PHOTO Louisville-based insurance company Humana is suing the U.S. government, a company spokesperson confirmed Friday.