Elevance pays CMS $342M to assuage concerns of noncompliance and overbilling
One of the largest Medicare Advantage insurers has agreed to pay back $342 million to the Centers for Medicare & Medicaid Services (CMS), in an effort to settle allegations that it overbilled the agency for patient care.
In agreeing to the payout—which was confirmed to have been wired to CMS on May 27, according to court records—the enforcement action against Elevance Health is still not officially settled. However, the payment, which the company said is equal to the total amount it was allegedly overpaid, is a step in that direction.
The full terms of a settlement are still being hammered out. But, the $342 million overbilling figure comes from an audit of Elevance Medicare Advantage plans conducted by CMS, the insurer said.
It contends that the remittance is equal to the estimate made by the agency.
A litany of compliance concerns
All the same, a simple payback may not be enough for federal regulators.
When filing its enforcement action in February—a precursor to a potential lawsuit—CMS warned Elevance that it was in danger of losing its contract with the government, with the agency halting enrollment in the company’s Medicare Part C plans as part of “intermediate sanctions.”
Those sanctions went into effect at the end of March and included a moratorium on communications with beneficiaries.
“The intermediate communications and enrollment sanctions will remain in effect until CMS is satisfied that the deficiencies upon which the determination was based have been corrected and are not likely to recur,” CMS wrote, adding that it will “provide Elevance with detailed instructions regarding the marketing and enrollment suspensions in a separate communication.”
CMS said the company has a history of repeated compliance failures that go beyond overbilling. According to the complaint, Elevance has submitted documentation and medical records via an encrypted flash drive, failing to use electronic reporting systems.
Those records, which include diagnostic and patient care data meant to justify the bills submitted to CMS, date back to 2018. CMS said noncompliance issues continued into October 2025.
For now, enrollment in Elevance Medicare Advantage plans remains on ice until the two parties come to terms.
HealthExec reached out to Elevance for comment.
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