The audit, published Oct. 4, examined nine diagnostic codes determined to be high risk for miscoding. The inspector general found for 207 of the 270 sampled enrollee years, the diagnosis codes the Medicare Advantage plan submitted to CMS were not supported by medical records.
CMS provides Medicare Advantage plans with monthly payments based on the risk status of enrollees. These risk statuses are calculated using diagnostic codes.
The inspector general recommends Humana refund the federal government the estimated $34.4 million in overpayments. The office published similar audits alleging overpayments on Sept. 30 and Oct. 3, requesting refunds from Highmark Senior Health Plan, BlueCross BlueShield of Tennessee and Inter Valley Health.
HumanaChoice disagreed with the inspector general’s findings and recommendations, according to the audit. The insurer, like the other plans audited, disputed the inspector general’s methodology used to calculate the estimated overpayments received.
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