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.”