A newly released Office of Inspector General (OIG) audit found that most of the high-risk diagnosis codes that the St. Louis-based Medicare Advantage (MA) organization submitted to the Centers for Medicare & Medicaid Services didn’t comply with federal requirements.
The audit focused on 10 groups of high-risk diagnosis codes that Coventry Health and Life Insurance Company submitted to Medicare’s risk adjustment program for payment years 2018 and 2019. The high-risk codes included those associated with acute stroke, acute myocardial infarction, embolism, sepsis, pressure ulcer, lung cancer, breast cancer, colon cancer, prostate cancer, and ovarian cancer.
OIG limited its review to portions of the payments associated with the high-risk codes and selected a stratified random sample of 300 enrollee-years from 2018 and 2019, which totaled $1.1 million.
The audit found medical records did not support the diagnosis codes submitted for 249 of the 300 sampled enrollee years and resulted in $752,587 in net overpayment. Based on the sample, the OIG estimated that Coventry received at least $6.9 million in net overpayments for 2018 and 2019.
The OIG recommended Coventry refund the $6.9 million, identify similar instances of noncompliance after the audit period and refund any additional overpayments to the federal government, and examine its existing compliance procedures to identify areas for improvement.
Coventry disagreed with all the findings and stated that the audit process was unfair, arbitrary and capricious, and contrary to law. The organization also argued that aspects of the audit were slanted in favor of alleged overpayments. The selection of audit years created a data validation problem because some providers lost medical records, so it prevented Coventry from retrieving the documentation support for physician diagnosis coding. OIG also sought to identify only overpayments, the organization said.