Priority Health is estimated to have collected at least $4.4 million in Medicare Advantage overpayments throughout 2018 and 2019, according to a March audit from the HHS Office of the Inspector General.
The audit focused on 10 high-risk diagnosis groups. HHS OIG said it is releasing a series of audits based on the data MA organizations submitted for risk adjustment.
Auditors found medical records did not back diagnosis codes across 252 of 300 sampled enrollee-years, prompting $828,010 in net MA overpayments. This sample indicates an 84% error rate. Many issues stemmed from coding a previous diagnosis as active.
“Priority’s policies and procedures to prevent, detect and correct noncompliance with CMS’ program requirements, as mandated by federal regulations, could be improved,” an HHS OIG news release said.
Priority contested 20 challenged enrollee-years but only succeeded in reversing five, the full report said. As a result, OIG lowered its overpayment estimate from $4,575,972 to $4,479,698, requesting that Priority pay back that amount. The auditors also asked Priority to identify other possible noncompliance incidents and review procedures to avoid miscoding.
While OIG issues recommendations, the report noted CMS finalizes overpayment actions.
“Priority Health takes compliance seriously and cooperated fully with the Office of Inspector General (OIG) audit of our Medicare Advantage risk adjustment payments,” an April 9 statement from Priority Health shared with Becker’s said. “The audit findings were anticipated and are consistent with industry trends. We continue to strengthen our internal processes to ensure accuracy and integrity in our operations. Priority Health remains committed to transparency and to delivering high-quality care to our members.”
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