6 Recent HHS OIG Medicare Advantage Compliance Audits

Medicare Advantage Compliance Audits: The Department of Health and Human Services Office of Inspector General regularly audits Medicare Advantage contracts and reports out specific diagnosis codes deemed improper. They also report the estimated overpayments associated with the specific diagnosis codes, and recommend repayments.  Below, you’ll find all of the specific “High Risk HCC codes” targeted in these recent HHS OIC Medicare Advantage compliance audits.

 

High Risk HCC codes targeted in 5 recent HHS OIC Medicare Advantage compliance audits:

And the organizations associated with misuse

 

Acute stroke: An enrollee received an acute stroke diagnosis (which maps to the HCC entitled Ischemic or Unspecified Stroke) on one or two physician claims during the service year but did not have that diagnosis on a corresponding inpatient hospital claim. A diagnosis of history of stroke (which indicates that the provider is evaluating or treating residual conditions left behind by a prior stroke and which does not map to an HCC) typically should have been used. Anthem, Coventry, Healthfirst, Tufts, UPMC

 

Major depressive disorder: An enrollee received a major depressive disorder diagnosis (which maps to the HCC entitled Major Depressive, Bipolar, and Paranoid Disorders) on one or two claims during the service year, rather than on several claims, which would have reflected long-term treatment. It is possible that a diagnosis of a less severe form of depression (which does not map to an HCC) should have been used. Anthem, Coventry, Healthfirst, Tufts, UPMC

 

Acute heart attack: An enrollee received one diagnosis that mapped to either the HCC for Acute Myocardial Infarction or to the HCC for Unstable Angina and Other Acute Ischemic Heart Disease (Acute Heart Attack HCCs) on only one physician claim but did not have that diagnosis on a corresponding inpatient hospital claim (either within 60 days before or 60 days after the physician’s claim). A diagnosis for a less severe manifestation of a disease in the related-disease group typically should have been used. Anthem, Coventry, Tufts, UPMC

 

Acute stroke and acute heart attack combination: An enrollee met the conditions of both the acute stroke and acute heart attack high-risk groups in the same year. Anthem, Coventry, Healthfirst, Tufts, UPMC

 

Incorrectly Submitted Diagnosis Codes for Vascular Claudication: Anthem, Coventry, Healthfirst, Tufts, UPMC

 

Embolism: An enrollee received one diagnosis that mapped to either the HCC for Vascular Disease or to the HCC for Vascular Disease With Complications (Embolism HCCs) but did not have an anticoagulant medication dispensed on his or her behalf. An anti-coagulant medication is typically used to treat an embolism. A diagnosis of history of embolism (an indication that the provider is evaluating a prior acute embolism diagnosis, which does not map to an HCC) typically should have been used. Anthem, Coventry, Healthfirst, Tufts, UPMC

 

Incorrectly Submitted Diagnosis Codes for Breast Cancer:  UPMC
Incorrectly Submitted Diagnosis Codes for Colon Cancer : , UPMC
Incorrectly Submitted Diagnosis Codes for Lung Cancer: , UPMC

 

Potentially Mis-keyed Diagnosis Codes: Anthem, Coventry, Healthfirst, Tufts, UPMC

 

 

Why OIG Does These Audits

 

Under the Medicare Advantage (MA) program, the Centers for Medicare & Medicaid Services (CMS) makes monthly payments to MA organizations according to a system of risk adjustment that depends on the health status of each enrollee. Accordingly, MA organizations are paid more for providing benefits to enrollees with diagnoses associated with more intensive use of health care resources than to healthier enrollees, who would be expected to require fewer health care resources.

 

To determine the health status of enrollees, CMS relies on MA organizations to collect diagnosis codes from their providers and submit these codes to CMS. Some diagnoses are at higher risk for being miscoded, which may result in overpayments from CMS.

 

In the past few months, a large number of these audits have been released. Here are the summaries of just a few.

 

HHS OIC Medicare Advantage compliance audit #1

Humana, Inc. – $197.7 Million

 

How OIG Did This Audit

For this audit, we reviewed one of the contracts that Humana, Inc., has with CMS with respect to the diagnosis codes that Humana submitted to CMS. Our objective was to determine whether Humana submitted diagnosis codes to CMS for use in the risk adjustment program in accordance with Federal requirements.

 

We selected a sample of 200 enrollees with at least 1 diagnosis code that mapped to an HCC for 2015. Humana provided medical records as support for 1,525 HCCs associated with the 200 enrollees. We used an independent medical review contractor to determine whether the diagnosis codes complied with Federal requirements.

 

Humana Did Not Submit Some Diagnosis Codes in Accordance With Federal Requirements

  1. Some of the Diagnosis Codes That Humana Submitted to CMS
    Were Not Supported in the Medical Records
  2. Diagnosis Codes That Humana Should Have Submitted but Did Not
    Submit to CMS

 

 

What OIG Found

Humana did not submit some diagnosis codes to CMS for use in the risk adjustment program in accordance with Federal requirements. First, although most of the diagnosis codes that Humana submitted were supported in the medical records and therefore validated 1,322 of the 1,525 sampled enrollees’ HCCs, the remaining 203 HCCs were not validated and resulted in overpayments. These 203 unvalidated HCCs included 20 HCCs for which we identified 22 other, replacement HCCs for more and less severe manifestations of the diseases. Second, there were an additional 15 HCCs for which the medical records supported diagnosis codes that Humana should have submitted to CMS but did not.

 

Thus, the risk scores for the 200 sampled enrollees should not have been based on the 1,525 HCCs. Rather, the risk scores should have been based on 1,359 HCCs (1,322 validated HCCs + 22 other HCCs + 15 additional HCCs). As a result, we estimated that Humana received at least $197.7 million in net overpayments for 2015. These errors occurred because Humana’s policies and procedures to prevent, detect, and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective.

 

What OIG Recommends and Humana’s Comments

We recommend that Humana refund to the Federal Government the $197.7 million of net overpayments and enhance its policies and procedures to prevent, detect, and correct noncompliance with Federal requirements for diagnosis codes that are used to calculate risk-adjusted payments.

 

Humana disagreed with our findings and with both of our recommendations. Humana provided additional medical record documentation which, Humana said, substantiated specific HCCs. Humana also questioned our audit and statistical sampling methodologies and said that our report reflected misunderstandings of legal and regulatory requirements underlying the MA program. After reviewing Humana’s comments and the additional information that it provided, we revised the number of unvalidated HCCs for this final report. We followed a reasonable audit methodology, properly executed our sampling methodology, and correctly applied applicable Federal requirements underlying the MA program. We revised the amount in our first recommendation from $263.1 million (in our draft report) to $197.7 million but made no change to our second recommendation.

Source: https://oig.hhs.gov/oas/reports/region7/71601165.pdf

 

HHS OIC Medicare Advantage compliance audit #2

UPMC Health Plan, Inc. –  $6.4 million

 

How OIG Did This Audit

For this audit, we reviewed one MA organization, UPMC Health Plan, Inc. (UPMC), and focused on 10 groups of high-risk diagnosis codes. Our objective was to determine whether selected diagnosis codes that UPMC submitted to CMS for use in CMS’s risk adjustment program complied with Federal requirements.

 

We sampled 280 unique enrollee-years with the high-risk diagnosis codes for which UPMC received higher payments for 2015 through 2016. We limited our review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $975,223.

 

Most of the Selected High-Risk Diagnosis Codes That UPMC Submitted to CMS Did Not Comply With Federal Requirements

  1. Incorrectly Submitted Diagnosis Codes for Acute Stroke
  2. Incorrectly Submitted Diagnosis Codes for Acute Heart Attack
  3. Incorrectly Submitted Diagnosis Codes for Acute Stroke and Acute Heart Attack Combination
  4. Incorrectly Submitted Diagnosis Codes for Major Depressive Disorder
  5. Incorrectly Submitted Diagnosis Codes for Embolism
  6. Incorrectly Submitted Diagnosis Codes for Vascular Claudication
  7. Incorrectly Submitted Diagnosis Codes for Lung Cancer
  8. Incorrectly Submitted Diagnosis Codes for Breast Cancer
  9. Incorrectly Submitted Diagnosis Codes for Colon Cancer
  10. Potentially Mis-keyed Diagnosis Codes

 

What OIG Found

With respect to the 10 high-risk groups covered by our audit, most of the selected diagnosis codes that UPMC submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 194 of the 280 enrollee-years, the diagnosis codes that UPMC submitted to CMS were not supported in the medical records and resulted in $681,099 of net overpayments for the 194 enrollee-years.

 

These errors occurred because the policies and procedures that UPMC had to ensure compliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective. On the basis of our sample results, we estimated that UPMC received at least $6.4 million of net overpayments for these high-risk diagnosis codes in 2015 and 2016.

 

What OIG Recommends and UPMC Comments

We recommend that UPMC refund to the Federal Government the $6.4 million of estimated net overpayments; identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government; and continue its examination of 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 (when submitted to CMS for use in CMS’s risk adjustment program) and take the necessary steps to enhance those procedures.

 

UPMC disagreed with our findings and recommendations. UPMC provided additional information which, according to UPMC, validated HCCs for 25 sampled enrollee-years. UPMC questioned both our audit methodology and the qualifications of our independent medical review contractor. UPMC also stated that we did not calculate overpayments according to CMS requirements and that it disagreed with our extrapolation methodology and our assessment of its compliance program. After reviewing UPMC’s comments and the additional information that it provided, we revised the number of enrollee-years in error for this final report. We followed a reasonable audit methodology, used a qualified medical review contractor, correctly applied applicable Federal requirements underlying the MA program, and properly assessed UPMC’s compliance program. We revised the amount in our first recommendation from $6.6 million (in our draft report) to $6.4 million but made no change to our other recommendations.

Source: https://oig.hhs.gov/oas/reports/region7/71901188.pdf

 

HHS OIC Medicare Advantage compliance audit #3

Healthfirst Health Plan, Inc. – ​​$5.2 million

 

How OIG Did This Audit

We sampled 240 unique enrollee-years with the high-risk diagnosis codes for which Healthfirst received higher payments for 2015 through 2016. We limited our review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $787,928.

 

Most of the Selected High-Risk Diagnosis Codes That Healthfirst Submitted to CMS Did Not Comply With Federal Requirements

  1. Incorrectly Submitted Diagnosis Codes for Acute Stroke
  2. Incorrectly Submitted Diagnosis Codes for Acute Stroke and Acute Heart Attack Combination
  3. Incorrectly Submitted Diagnosis Codes for Embolism
  4. Incorrectly Submitted Diagnosis Codes for Vascular Claudication
  5. Incorrectly Submitted Diagnosis Codes for Major Depressive Disorder
  6. Potentially Mis-keyed Diagnosis Codes

 

What OIG Found

With respect to the seven high-risk groups covered by our audit, most of the selected diagnosis codes that Healthfirst submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 155 of the 240 enrollee-years, the diagnosis codes that Healthfirst submitted to CMS were not supported in the medical records and resulted in net overpayments of $516,509.

 

These errors occurred because the policies and procedures that Healthfirst had to detect and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective. On the basis of our sample results, we estimated that Healthfirst received at least $5.2 million in net overpayments for these high-risk diagnosis codes in 2015 and 2016.

 

What OIG Recommends and Healthfirst Comments

We made a series of recommendations to Healthfirst, including that it: refund to the Federal Government the $5.2 million of net overpayments; identify, for the diagnosis codes described in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government; and continue its examination of existing compliance procedures to identify areas where improvements can be made to ensure diagnosis codes that are at high risk for being miscoded comply with Federal requirements and take the necessary steps to enhance those procedures.

 

Healthfirst objected to all of our recommendations; however, it did not object to any of the errors we identified. Instead, Healthfirst requested we limit our recommended recovery to the overpayments identified in our sample-not the extrapolated value of those overpayments. Healthfirst stated that OIG lacked the authority to use extrapolation to recommend a repayment and disagreed with our extrapolation methodology. It also stated that our audit methodology did not account for a payment principle known as “actuarial equivalence” and disagreed that it should perform audits of high-risk diagnoses or enhance its compliance program. After reviewing Healthfirst’s comments, we maintain that our findings and recommendations are valid. No statutory authority limits our use of extrapolation to estimate a recovery and we correctly applied Federal requirements underlying the MA program.

Source: https://oig.hhs.gov/oas/reports/region2/21801029.pdf

 

HHS OIC Medicare Advantage compliance audit #4

Tufts Health Plan –  $3.7 million

 

How OIG Did This Audit

For this audit, we reviewed one MA organization, Tufts Health Plan, Inc. (Tufts), and focused on seven groups of high-risk diagnosis codes. Our objective was to determine whether selected diagnosis codes that Tufts submitted to CMS for use in CMS’s risk adjustment program complied with Federal requirements.

 

We sampled 212 unique enrollee-years with the high-risk diagnosis codes for which Tufts received higher payments for 2015 through 2016. We limited our review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $746,427.

 

Most of the Selected High-Risk Diagnosis Codes That Tufts Health Plan Submitted to CMS Did Not Comply With Federal Requirements

  1. Incorrectly Submitted Diagnosis Codes for Acute Stroke
  2. Incorrectly Submitted Diagnosis Codes for Acute Heart Attack
  3. Incorrectly Submitted Diagnosis Codes for Acute Stroke and Acute Heart Attack Combination
  4. Incorrectly Submitted Diagnosis Codes for Embolism
  5. Incorrectly Submitted Diagnosis Codes for Vascular Claudication
  6. Incorrectly Submitted Diagnosis Codes for Major Depressive Disorder
  7. Potentially Mis-keyed Diagnosis Codes

 

What OIG Found

Most of the selected diagnosis codes that Tufts submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 58 of the 212 sampled enrollee-years, the medical records validated the reviewed Hierarchical Condition Categories (HCCs). However, for the remaining 154 enrollee-years, the diagnosis codes were not supported in the medical records. These errors occurred because the policies and procedures that Tufts had to ensure compliance with CMS’s program requirements, as mandated by Federal regulations, could be improved. As a result, the HCCs for some of the high-risk diagnosis codes were not validated. On the basis of our sample results, we estimated that Tufts received at least $3.7 million of net overpayments for these high-risk diagnosis codes in 2015 and 2016.

 

What OIG Recommends

We recommend that Tufts: (1) refund to the Federal Government the $3.7 million of net overpayments; (2) identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government; and (3) continue to improve its existing compliance procedures to identify areas where improvements can be made to ensure diagnosis codes that are at high risk for being miscoded comply with Federal requirements (when submitted to CMS for use in CMS’s risk adjustment program) and take the necessary steps to enhance those procedures.

 

Tufts did not concur with our findings and recommendations. Tufts stated that we should not have included the errors associated with 5 enrollee-years in our calculation of total net overpayments because, according to Tufts, it had already submitted corrections to CMS. Tufts did not specifically comment on the errors associated with the other 154 enrollee-years. Tufts disagreed with our sampling and review methodologies, and stated that our report reflected misunderstandings of legal and regulatory requirements underlying the MA program.

 

After consideration of Tufts’ comments, we maintain that our findings and recommendations are valid. However, we revised our findings for the 5 enrollee-years and considered the impact of the budget sequestration reduction; therefore, we reduced our first recommendation from $4,013,034 to $3,758,335 for our final report. We also revised the beginning of our third recommendation in recognition of Tuft’s past efforts to improve its compliance program.

Source: https://oig.hhs.gov/oas/reports/region1/11900500.pdf

 

HHS OIC Medicare Advantage compliance audit #5

Anthem Community Insurance Company, Inc. – $3.47 million

 

How OIG Did This Audit

For this audit, we reviewed one MA organization, Anthem Community Insurance Company, Inc. (Anthem), and focused on seven groups of high-risk diagnosis codes. Our objective was to determine whether selected diagnosis codes that Anthem submitted to CMS for use in CMS’s risk adjustment program complied with Federal requirements.

 

We sampled 203 unique enrollee-years with the high-risk diagnosis codes for which Anthem received higher payments for 2015 through 2016. We limited our review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $599,842.

 

Most of the Selected High-Risk Diagnosis Codes That Anthem Submitted to CMS Did Not Comply With Federal Requirements

  1. Incorrectly Submitted Diagnosis Codes for Acute Stroke
  2. Incorrectly Submitted Diagnosis Codes for Acute Heart Attack
  3. Incorrectly Submitted Diagnosis Codes for Acute Stroke and
    Acute Heart Attack Combination
  4. Incorrectly Submitted Diagnosis Codes for Embolism
  5. Incorrectly Submitted Diagnosis Codes for Vascular Claudication
  6. Incorrectly Submitted Diagnosis Codes for Major Depressive Disorder
  7. Potentially Mis-keyed Diagnosis Codes

 

What OIG Found

With respect to the seven high-risk groups covered by our audit, most of the selected diagnosis codes that Anthem submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 123 of the 203 enrollee-years, the diagnosis codes that Anthem submitted to CMS were not supported in the medical records and resulted in $354,016 of net overpayments for the 203 enrollee-years.

 

These errors occurred because the policies and procedures that Anthem had to detect and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective. On the basis of our sample results, we estimated that Anthem received at least $3.47 million of net overpayments for these high-risk diagnosis codes in 2015 and 2016.

 

What OIG Recommends and Anthem Comments

We recommend that Anthem refund to the Federal Government the $3.47 million of net overpayments; identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government; and enhance its compliance procedures to focus on diagnosis codes that are at high risk for being miscoded by (1) determining whether these diagnosis codes (when submitted to CMS for use in CMS’s risk adjustment program) comply with Federal requirements and (2) educating its providers about the proper use of these diagnosis codes.

 

Anthem did not concur with our findings and recommendations. Anthem disagreed with our findings for 2 specific enrollee-years and provided additional explanations. Anthem also did not agree with the methodologies that we used to review the selected diagnoses and to calculate the $3.47 million of net overpayments. Anthem also said that our report reflected misunderstandings of legal and regulatory requirements underlying the MA program.

 

After reviewing Anthem’s comments and the information provided, we maintain that all of our findings and recommendations remain valid. We followed a reasonable audit methodology, properly executed our sampling methodology, and correctly applied applicable Federal requirements underlying the MA program.

Source: https://oig.hhs.gov/oas/reports/region7/71901187.pdf

 

HHS OIC Medicare Advantage compliance audit #6

Coventry Health Care of Missouri, Inc. – $548,852

 

How OIG Did This Audit

For this audit, we reviewed one MA organization, Coventry Health Care of Missouri, Inc. (Coventry), and focused on six groups of high-risk diagnosis codes. Our objective was to determine whether selected diagnosis codes that Coventry submitted to CMS for use in CMS’s risk adjustment program complied with Federal requirements.

 

We judgmentally selected 275 unique enrollee-years with the high-risk diagnosis codes for which Coventry received higher payments for 2014 through 2016. We limited our review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $701,593.

 

Most of the Selected High-Risk Diagnosis Codes That Coventry Submitted
to CMS Did Not Comply With Federal Requirements

  1. Incorrectly Submitted Diagnosis Codes for Acute Stroke
  2. Incorrectly Submitted Diagnosis Codes for Acute Heart Attack
  3. Incorrectly Submitted Diagnosis Codes for Embolism
  4. Incorrectly Submitted Diagnosis Codes for Vascular Claudication
  5. Incorrectly Submitted Diagnosis Codes for Major Depressive Disorder
  6. Potentially Mis-keyed Diagnosis Codes

 

What OIG Found

Most of the selected diagnosis codes that Coventry submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 226 of the 275 enrollee-years, the diagnosis codes that Coventry submitted to CMS were not supported in the medical records.

 

These errors occurred because the policies and procedures that Coventry had to detect and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective. As a result, Coventry received $548,852 of net overpayments for 2014 through 2016.

 

What OIG Recommends and Coventry’s Comments

We recommend that Coventry refund to the Federal Government the $548,852 of net overpayments; identify, for the diagnoses included in this report, similar instances of noncompliance that occurred during our audit period that we did not review and outside of our audit period and refund any resulting overpayments to the Federal Government; and enhance its compliance procedures to focus on diagnosis codes that are at high risk for being miscoded by: (1) educating its providers about the proper use and documentation of these diagnoses and (2) determining whether these diagnosis codes (when submitted to CMS for use in CMS’s risk adjustment program) comply with Federal requirements.

 

Coventry agreed that most of the reviewed diagnosis codes were not supported by medical records and said that it had identified $542,541 to refund to the Federal Government. However, Coventry did not agree with the other findings associated with our first recommendation and submitted additional documentation for our consideration. Coventry did not agree with our other recommendations and said that our report contained a number of serious flaws that fundamentally undermined our audit methodology, findings, and recommendations. Coventry also stated that it had made enhancements to its compliance processes since our audit period, including provider education.

 

After reviewing Coventry’s comments and the additional documentation that it provided, we revised the number of enrollee-years in error. We followed a reasonable audit methodology, properly executed our sampling methodology, and correctly applied applicable Federal requirements underlying the MA program. We revised the recommendation to refund overpayments from $584,005 (in our draft report) to $548,852 and slightly revised some of the language in our third recommendation.

Source: https://oig.hhs.gov/oas/reports/region7/71701173.pdf

 

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