HSS’ Office of Inspector General estimates that BCBS Alabama received at least $7 million in Medicare Advantage overpayments, according to a March audit report.
From a sample of 271 enrollee-years, 247 had medical records that did not align with diagnosis codes, prompting just over $769,000 in overpayments. This sample came from 3,706 unique enrollee-years wherein providers documented high-risk diagnosis codes throughout the 2017 and 2018 service years.
Looking at the sample, OIG found that lung cancer, pressure ulcers, sepsis, embolisms, colon cancer, acute strokes and acute myocardial infarctions were the largest drivers of overpayments, in that order. Issues stemmed from providers filing diagnoses as “active” conditions versus historical ones, along with insufficient supporting documentation.
During the 2018 and 2019 payment years, CMS paid the insurer about $1.8 billion for MA.
The report added that BCBS Alabama did not concur with the finding for 64 reviewed enrollee-years. In a statement shared with Becker’s March 18, the insurer said it “strongly disagree[s] with the approach” of the audit.
“The coding mistakes were made on claims from provider practices submitted to BCBS of Alabama,” the insurer said in a March 18 statement shared with Becker’s. “These findings therefore show gaps in documentation and coding accuracy, not fraud or intentional misconduct.”
BCBS Alabama said repayments are not confirmed yet as OIG hands over its findings to CMS.
