5 payers flagged for coding, reimbursement errors

A handful of payers were flagged by HHS' Office of the Inspector General in the last six months for coding or reimbursement errors. 

Here are five instances, as reported by Becker's Hospital Review:

1. Tufts Health Plan. Tufts Health Plan received $3.7 million in Medicare Advantage overpayments, the OIG found Feb. 14. The audit analyzed the payer's use of high-risk diagnostic codes between 2015 and 2016. The OIG found that of the 212 enrollee years analyzed, 154 didn't have diagnostic codes supported by medical records, resulting in overpayments. The payer did not agree with the findings or recommendations, saying it had self-reported some errors and already corrected five enrollee years. Despite the health plan's objections, the OIG maintained most of its findings but adjusted the initial $4 million figure down to $3.7 million. 

2. SCAN Health Plan. An OIG audit found SCAN Health Plan received $54.3 million in overpayments for its Medicare Advantage claims. The audit looked at diagnosis codes used to determine risk adjustment payments. The audit looked at a sample of 200 enrollees with at least one diagnosis code that mapped to hierarchical condition categories for 2015. The office found 164 of the 1,577 associated hierarchical condition categories were not supported by medical records provided by SCAN Health Plan. Due to the error, the payer's 2015 risk score should have been calculated based on 1,454 HCCs. The difference resulted in the estimated $54.3 million in overpayments. SCAN Health Plan contested the audit and said many of the HCCs were unvalidated. OIG reviewed its findings and stood by its estimation. 

3. Healthfirst Health Plan. An OIG audit of Healthfirst Health Plan found the payer received $5.2 million in overpayments between 2015 and 2016 resulting from coding errors. Specifically, the office studied diagnosis codes submitted for use in CMS' risk adjustment program and found that of the 240 enrollee years in the audit, 151 were not supported by member medical records. Healthfirst objected to the recommendations and believed CMS' estimate of $5.2 million was inaccurate.

4. UPMC. HHS found that a handful of UPMC's health plans received $6.4 million in overpayments in 2015 and 2016 because several high-risk diagnosis codes did not meet federal guidelines. UPMC disagreed with figures presented in the initial audit. The audit recommended the health plans refund the overpayments and review compliance.  

5. TennCare. An Oct. 21 Tennessee Medicare audit revealed that TennCare received $482.1 million in excess certified public expenditures. HHS recommended that TennCare refund $397.4 million in alleged overpayments, along with $370.1 million for uninsured patients' mental healthcare that didn't have proper documentation. The OIG also recommended TennCare implement policies to comply with federal guidelines. TennCare Director Stephen Smith said, "We're going to actively refute the OIG findings. We're going to take all necessary steps in appeals to avoid any unwarranted repayment."

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