{"id":26982,"date":"2026-06-26T14:34:53","date_gmt":"2026-06-26T09:04:53","guid":{"rendered":"https:\/\/banitoday.com\/medicare-advantage-company-pays-342m-to-government-in-midst-of-billing-probe\/"},"modified":"2026-06-26T14:34:53","modified_gmt":"2026-06-26T09:04:53","slug":"medicare-advantage-company-pays-342m-to-government-in-midst-of-billing-probe","status":"publish","type":"post","link":"https:\/\/banitoday.com\/hi\/medicare-advantage-company-pays-342m-to-government-in-midst-of-billing-probe\/","title":{"rendered":"Medicare Advantage Company Pays $342M to Government in Midst of Billing Probe"},"content":{"rendered":"


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A major Medicare Advantage company has paid the government more than $342 million to help settle allegations that it overcharged the federal healthcare program for years.<\/p>\n

Elevance Health, which covers about 2 million people on Medicare, sent the money to the Centers for Medicare & Medicaid Services via wire transfer on May 27, court records show. Government lawyers disclosed the payment in a June 22 court filing.<\/p>\n

In an email to CMS staff, Elevance described the money as a \u201cremittance of the total overpayment amount\u201d estimated by government audits, court records show. Company spokesperson Leslie Porras told KFF Health News in a statement that Elevance Health \u201ccontinues to engage in constructive dialogue\u201d with CMS. \u201cWe remain optimistic that a resolution can be reached and value our longstanding relationship with CMS,\u201d she said.<\/p>\n

The payment was made in response to a CMS enforcement action in February<\/a>, in which the agency threatened to halt enrollments in Elevance Medicare Advantage plans unless the company corrected what CMS called \u201csubstantial and persistent noncompliance\u201d with federal regulations that require health plans to submit accurate billing data and return any overpayments when they are discovered.<\/p>\n

It appears to be the first time CMS has successfully pressured a Medicare Advantage health plan to pay back tens of millions of dollars in alleged overpayments \u2014 even though agency officials have known for years that many health plans have overbilled the program, according to audits by government staff.<\/p>\n

\u201cI\u2019ve never heard of something like this before,\u201d said David Lipschutz, an attorney with the Center for Medicare Advocacy, a nonprofit public interest law firm. \u201cUsually plans seem to tie everything up and try to delay any repayment of anything for years.\u201d<\/p>\n

David Meyers, an associate professor at the Brown University School of Public Health, called the payment \u201csubstantial\u201d and \u201ca step in the right direction\u201d toward holding the industry accountable.<\/p>\n

\u201cIt\u2019s a big win for CMS to get that much,\u201d he said.<\/p>\n

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More than 35 million Americans<\/a>, about 55% of people on Medicare, have signed up for the private Advantage health insurance plans, which offer extra benefits, such as hearing aids and dental coverage, that traditional Medicare doesn\u2019t cover.<\/p>\n

Joining the plans may also prove cheaper for patients than purchasing a supplemental insurance policy that covers gaps in traditional Medicare.<\/p>\n

Whether Medicare Advantage is a good deal for taxpayers is hotly debated, however.<\/p>\n

The health plans have been the target of dozens of whistleblower lawsuits<\/a> and government investigations alleging they often exaggerate how sick patients are to improperly boost their payments, claims the industry disputes. Medicare pays health plans higher rates for sicker patients but requires that the plans bill only for conditions that are properly documented in a patient\u2019s medical records.<\/p>\n

Researchers also have concluded that Medicare overpays the health plans<\/a> by billions of dollars every year because of medical coding flaws that generate higher bills than are justified.<\/p>\n

The whistleblower suits, mostly filed by former employees of healthcare companies, have long served as the primary tool for clawing back alleged overpayments. In January, Kaiser Permanente agreed to pay $556 million<\/a> to settle Justice Department allegations that it billed the government for medical conditions patients didn\u2019t have, the largest such penalty to date. In a statement posted<\/a> on its website, the company said it settled the case \u201cto avoid the delay, uncertainty, and cost of prolonged litigation.\u201d<\/p>\n

By contrast, CMS\u2019 efforts to prevent Medicare Advantage plans from overcharging have largely foundered.<\/p>\n

In 2014, for instance, CMS backed off<\/a> a proposed regulation that would have cracked down on overbilling amid an \u201cuproar\u201d of opposition from the industry. And even when CMS audits uncovered tens of millions of dollars in overpayments, agency officials collected only a tiny fraction<\/a> of that amount.<\/p>\n

The CMS threat to bar Elevance from enrolling new members may open a new approach.<\/p>\n

\u201cThe payment Elevance is making here is not trivial,\u201d said Matthew Fiedler, a health policy researcher at the Brookings Institution.<\/p>\n

But he noted that it represents a very small fraction of the total the company receives from Medicare. He said that making a big dent in the overpayment problem would require CMS to collect \u201cmany similar payments\u201d \u2014 from \u201cevery\u201d Medicare Advantage insurer.<\/p>\n

\u201cI don\u2019t think there\u2019s a clear reason to believe that at this stage,\u201d Fiedler said.<\/p>\n

Richard Kronick, a former federal health policy official and a professor at the University of California-San Diego, agreed that the payment reflects a small portion of the company\u2019s revenue. But he said it was \u201cstill a sizable check to write.\u201d<\/p>\n

Kronick said the action reflects \u201cperhaps a bit of muscle flexing\u201d by CMS to tighten up enforcement.<\/p>\n

CMS did not immediately respond to a request for comment. It\u2019s not clear from court records whether the payment will end the CMS threat to ban Elevance from signing up new members.<\/p>\n

If so, it might prove to be a relative bargain. In an April filing<\/a> with the Securities and Exchange Commission, the company noted that its \u201ccurrent best estimate\u201d of the \u201cpotential exposure\u201d in the case was approximately $935 million.<\/p>\n

Elevance has been at odds with the federal government over its billing practices since 2020, when the Justice Department filed a False Claims Act lawsuit<\/a> against the company, then known as Anthem. That case is pending.<\/p>\n

Court filings in that case disclosed the company\u2019s payment to CMS. In an email made part of the court file, a company official confirmed it had sent the wire transfer in the amount of $342,209,085.30 on May 27 and said the payment was related to the threatened enrollment ban. The company also stated that it was challenging the CMS enforcement action and called it \u201cunprecedented.\u201d<\/p>\n

In defending against the Justice Department suit, Elevance has denied wrongdoing and argued that CMS knew about its billing practices for years and took no action.<\/p>\n

Meyers, the Brown University professor, said CMS\u2019 success in collecting payment from Elevance may encourage more enforcement.<\/p>\n

\u201cIt remains to be seen whether this is a sea change,\u201d he said.<\/p>\n<\/div>\n


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A major Medicare Advantage company has paid the government more than $342 million to help settle allegations that it overcharged the federal healthcare program for years. Elevance Health, which covers about 2 million people on Medicare, sent the money to the Centers for Medicare & Medicaid Services via wire transfer on May 27, court records […]<\/p>\n","protected":false},"author":1,"featured_media":10378,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[270],"tags":[],"class_list":["post-26982","post","type-post","status-publish","format-standard","has-post-thumbnail","category-health-2"],"amp_enabled":true,"_links":{"self":[{"href":"https:\/\/banitoday.com\/hi\/wp-json\/wp\/v2\/posts\/26982","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/banitoday.com\/hi\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/banitoday.com\/hi\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/banitoday.com\/hi\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/banitoday.com\/hi\/wp-json\/wp\/v2\/comments?post=26982"}],"version-history":[{"count":0,"href":"https:\/\/banitoday.com\/hi\/wp-json\/wp\/v2\/posts\/26982\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/banitoday.com\/hi\/wp-json\/wp\/v2\/media\/10378"}],"wp:attachment":[{"href":"https:\/\/banitoday.com\/hi\/wp-json\/wp\/v2\/media?parent=26982"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/banitoday.com\/hi\/wp-json\/wp\/v2\/categories?post=26982"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/banitoday.com\/hi\/wp-json\/wp\/v2\/tags?post=26982"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}