OIG audit: Excellus Health Plan received $5.4M in MA overpayments

The compliance audit of Excellus Health Plan, Inc., a Medicare Advantage organization based in Rochester, N.Y. that had approximately 96,254 enrollees in 2018, found that 202 of the 210 medical records sampled did not support seven high-risk diagnosis codes submitted and resulted in nearly $480,000 in overpayments.

Based on the sample results, OIG estimated that Excellus received approximately $5.4 million in overpayments for 2017 and 2018. However, because federal regulations were updated after the OIG issued its draft report and limited the use of extrapolation in Risk Adjustment Data Validation audits for recovery purposes to payment years 2018 and forward, the watchdog recommends a refund of $3.1 million. The revised figure is based on $235,453 for the sampled enrollee years from 2017 and an estimated $2.9 million for 2018).

According to the audit, Excellus incorrectly submitted diagnosis codes for acute stroke, acute myocardial infarction, embolism, lung cancer, breast cancer, colon cancer, and prostate cancer. As a result, OIG recommends that Excellus:

Refund Medicare the $3.1 million of estimated overpayments
Identify similar instances of noncompliance for the high-risk diagnosis that occurred before or after the audit period and refund any resulting overpayments to Medicare
Identify compliance procedures that could be improved to ensure that diagnosis codes that are at high risk for being miscoded comply with federal requirements and take the necessary steps to enhance those procedures

Excellus disagreed with OIG’s recommendations as well as the findings for two sampled enrollee years which the organization argued were supported by the medical records. It also disagreed with the watchdog’s audit methodology, use of extrapolation, standards for data accuracy, and medical record review process. After reviewing the organization’s comments, OIG said its findings and recommendations are valid.