RISE summarizes recent Medicare Advantage news, including Office of Inspector General (OIG) audits that show two MA plans owe the federal government millions in overpayments and a ruling that will allow a Department of Justice (DOJ) fraud case against Anthem to move forward.

OIG: HumanaChoice owes $34.4M in overpayments for high-risk diagnosis codes

The OIG this week released the results of its audit of HumanaChoice, which focused on nine groups of high-risk diagnosis codes that the Medicare Advantage (MA) plan submitted to the Centers for Medicare & Medicaid Services (CMS) for use in its risk adjustment program. The OIG sampled 270 unique enrollee-years with the high-risk diagnosis codes for which HumanaChoice received higher payments for 2016 and 2017.

According to the OIG, most of the selected diagnosis codes that the plan submitted to CMS didn’t comply with federal requirements. OIG said that the medical records did not support the submitted diagnosis codes in 207 of the samples and resulted in $574,430 of overpayments. Based on the sample results, the OIG estimated that HumanaChoice received at least $34.4 million of overpayments for these high-risk diagnosis codes in 2016 and 2017.

The OIG recommended that HumanaChoice return the overpayments to Medicare, identify similar instances of noncompliance of high-risk diagnoses that occurred before of after the OIG audit report and refund any additional overpayments, and review its existing compliance procedures to improve areas where diagnosis codes are at high risk for being miscoded. HumanaChoice disagreed with the initial findings and recommendations and submitted additional information for 10 sampled enrollee-years that supported the diagnosis codes. As a result, the final report reflects the number of enrollee-years in error from 208 to 207 and overpayments of $34.4 million instead of the $34.8 million stated in the draft report. However, the OIG’s other recommendations remain unchanged.

OIG: Highmark owes $6.2M in overpayments

The OIG also released the results of its recent audit of Highmark Senior Health Company, which focused on high-risk diagnosis codes submitted to CMS for its risk adjustment program. The audit focused on 226 unique enrollee condition and payment years with the high-risk diagnosis codes for which Highmark received higher payments for 2015 and 2016. Highmark received $801,166 for these codes.

The OIG determined that the diagnosis codes weren’t support in the documentation contained in the medical records for 160 of the 226 sampled enrollee-years. These errors occurred because the policies and procedures in place at Highmark were insufficient to validate the high-risk diagnosis codes. The OIG estimated that Highmark received at least $6.2 million of net overpayments for 2015 and 2016.

The watchdog recommended that Highmark return the $6.2 million in overpayments to Medicare, identify similar instances of noncompliance that occurred before or after the audit period and refund any resulting overpayments to the federal government, and improve its existing compliance procedures. Highmark reviewed the draft report and disagreed with the findings and recommendations. It provided additional information for two medical records to support the coding. After reviewing the comments and additional information, the OIG revised the findings as indicated in the final report.

Anthem MA fraud case to move forward

A federal judge has ruled Anthem Inc. must face a U.S. government lawsuit that claims the insurer fraudulently submitted inaccurate diagnosis data and collected millions of dollars in overpayments from Medicare. U.S. District Judge Andrew Carter said that the overpayment appears to be well over $100 million, a substantial cost to the federal government, Reuters reported. The Department of Justice filed the lawsuit in March 20202, claiming that Anthem failed to delete inaccurate diagnosis codes submitted to Medicare between early 2014 and early 2018. The complaint says Anthem didn’t delete the invalid codes because it would have reduced the additional revenue its chart review program generated for the insurer.