|
 The unanimous ruling by a panel of the D.C. Circuit Court of Appeals
in Washington was a setback for UnitedHealth Group Inc, which had
successfully challenged the rule in a lower court.
UnitedHealth did not immediately respond to a request for comment.
Nor did the U.S. Department of Health and Human Services, which
oversees Medicare, the federal health insurance program for seniors
and certain people with disabilities.
The 2014 rule applies to so-called Medicare Advantage insurance
plans, which are funded through HHS but administered by private
insurers like UnitedHealth.
HHS pays Medicare Advantage plans a base amount per beneficiary,
adjusted according to diagnostic codes reflecting each beneficiary's
individual risk factors.
Under the rule, if a Medicare Advantage insurer learns that it
received a payment based on an unsupported diagnosis, it must return
that payment within 60 days.
According to a 2016 federal audit, the government paid out about
$16.2 billion that year based on unsupported diagnoses, nearly 10%
of the total paid to Medicare Advantage insurers.
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 In its 2016 lawsuit,
UnitedHealth argued that the overpayment rule
treated Medicare Advantage differently from
traditional Medicare, which pays providers on a
fee-for-service basis and does not
comprehensively audit claims for overpayments.
The insurer said the difference ran afoul of the
Medicare law's requirement of "actuarial
equivalence" between Medicare Advantage and
traditional Medicare.
In 2018, U.S. District Judge Rosemary Collyer in
Washington agreed, overturning the rule.
Circuit Judge Cornelia Pillard, however, wrote
for the appeals court panel Friday that there
was "no basis" to conclude that Congress
intended the actuarial equivalence requirement
to "thwart" insurers' obligation to return
overpayments.
(Reporting by Brendan Pierson in New York;
Editing by Steve Orlofsky)
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