The audit by the Office of Inspector General (OIG) focused on eight diagnoses codes at high risk of being miscoded and found that most of Humana’s submissions did not comply with federal requirements for the Centers of Medicare & Medicaid Services’ (CMS) risk adjustment program.
OIG’s audit focused on Humana’s Medicare Advantage organization in Louisville, Ky., which provides coverage to 247,872 seniors for payment years 2017 and 2018. During the audit period, CMS paid Humana approximately $5 billion to provide coverage to its enrollees.
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OIG used a random sample of 240 unique enrollee years, focusing the review on payments associated with the high-risk diagnosis codes, which totaled $642,816. The high-risk codes included those associated with acute stroke, acute myocardial Infarction, embolism, sepsis, lung cancer, breast cancer, colon cancer, and prostate cancer.
Auditors found that for 202 of the 240 sampled enrollee years, the diagnoses codes that Humana submitted to CMS were not supported by documentation in the medical records and resulted in $497,225 in overpayments. Based on those sample results, OIG estimated that Humana received at least $13.1 million in overpayments for 2017 and 2018. However, because federal regulations limit the use of extrapolation in Risk Adjustment Data Validation audits for recovery purposes to payment years 2018 and forward. OIG recommends Humana repay the federal government $6.8 million (247,151 for the sampled years from 2017 and an estimated $6.5 million for 2018).
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In addition to the refund to the federal government, OIG recommends that Human take the following actions:
- Identify similar instances of noncompliance with the high-risk diagnoses before or after the audit period and refund any resulting overpayments.
- Review its existing compliance procedures to identify areas where improvements can be made 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.
According to the audit report, Humana disagreed with the findings for 33 of the 206 enrollee years identified as errors in the initial report and provided additional information for consideration. The health plan also did not agree with OIG’s audit methodology or overpayment estimation methodology. OIG reviewed the additional information and reduced the number of enrollee years identified as errors in the final report and revised the amount in its first recommendation. It stands by the other two recommendations.