The Office of Inspector General (OIG) audited UPMC Health Plan, Inc. to determine whether the Medicare Advantage organization appropriately submitted selected diagnoses codes to the Centers for Medicare & Medicaid Services’ (CMS) risk adjustment program.

The audit is part of a series of audits that the OIG is conducting to determine the accuracy of diagnoses codes that Medicare Advantage organizations submitted to CMS.

The OIG said in the November report that it focused its review on 280 unique enrollee-years and the payments that UPMC received for 10 groups of high-risk diagnosis codes in 2015 through 2016, which totaled $975,223. Those codes include acute stroke, acute heart attack, acute stroke and acute heart attack combination, major depressive disorder, embolism, vascular claudication, lung cancer, breast cancer, colon cancer, and potentially mis-keyed diagnosis codes.

Most of the selected diagnoses codes that UPMC submitted to CMS for the agency’s risk adjustment program did not comply with federal requirements, according to the 76-page report. Documentation in the medical record did not support the submission of diagnoses codes for 194 of the 280 enrollee years and resulted in close to $682,000 of net overpayments.

Based on the sample results, OIG estimates that UPMC received at least $6.4 million of net overpayments for these high-risk diagnoses codes in 2015 and 2016 and asked the Medicare Advantage plan to refund the money and review its compliance program.

UPMC disagreed with the findings and questioned the OIG’s methodology. It also provided OIG with additional information that validated HCCs for 25 sampled enrollee years. The organization argued that the OIG did not calculate overpayments according to CMS requirements and disagreed with the agency’s extrapolation methodology and assessment of its compliance program.

After reviewing UPMC's comments and the additional information that it provided, OIG revised the number of enrollee-years in error for the final report. It said it followed a reasonable audit methodology, used a qualified medical review contractor, correctly applied applicable federal requirements underlying the Medicare Advantage program, and properly assessed UPMC's compliance program. We revised the amount in its first recommendation from $6.6 million in the draft report to $6.4 million but made no change to the other recommendations.