Anthem Is Second Insurer to Refute OIG Risk Score Review

In the second example in recent months of a Medicare Advantage insurer disputing the federal government’s method of identifying overpayments, a new HHS Office of Inspector General audit report limited its review to a group of diagnosis codes that it maintained are at a particular risk for being miscoded. In addition to having routine medical record review and auditing activities, MA plan sponsors should take extra precautions to identify provider trends in this high-risk group for more accurate risk adjustment, one industry expert suggests.

Conducted separately from CMS’s contract-level Risk Adjustment Data Validation (RADV) audits that verify the accuracy of payments made to MA organizations, the recent findings are part of a series of audits in which OIG is reviewing the accuracy of diagnosis codes submitted to CMS. In a similar report released in April, OIG estimated that Humana Inc. received nearly $200 million in net overpayments for a contract serving approximately 485,000 enrollees. Humana at the time disputed the findings and said it would have the right to appeal “if CMS does determine that an overpayment exists.”

© 2021 MMIT

Lauren Flynn Kelly Managing Editor, Radar on Medicare Advantage

Lauren has been covering health business issues, including drug benefits and specialty pharmacy, for more than a decade. She served as editor of Drug Benefit News (the predecessor to Radar on Drug Benefits) from 2004 to 2005 and again from 2011 to 2016, and now manages Radar on Medicare Advantage. Lauren graduated from Vassar College with a B.A. in English.

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