5 payers tagged by OIG for coding, reimbursement errors in 2021

A handful of payers were flagged throughout 2021 by HHS' Office of the Inspector General for coding or reimbursement errors.

Here are five payers tagged this year, as reported by Becker's Hospital Review:

1. Humana: HHS found April 20 that Humana received $197.7 million in overpayments due to noncompliance with federal coding requirements. An investigation found that 203 of 1,525 enrollees' health risk scores were unvalidated and therefore resulted in overpayments. A Humana spokesperson told Becker's that it "will work cooperatively with CMS, as we did with HHS OIG, to resolve this review. As the report acknowledges, the recommendations do not represent final determinations, and Humana will have the right to appeal if CMS does determine an overpayment exists."

2. 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, $370.1 million in caring for uninsured patients' mental healthcare without documentation and 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."

3. UPMC: HHS found Nov. 5 that a handful of UPMC's health plans received $6.4 million in overpayments 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.  

4. Anthem: HHS flagged Anthem on May 24 for failing to comply with federal coding guidelines, resulting in $3.47 million in overpayments. The audit found that 123 of the 203 enrollee-years sampled included a claim that were not supported by medical records. The payer contested both the Office of the Inspector General's methodology and its review of two specific enrollee-years from the sample. 

5. UnitedHealthcare: Of a pool of 20 anonymous payers flagged in a September HHS report for receiving over $9.2 billion in suspicious Medicare payments, UnitedHealthcare was later revealed to hold the largest share of the pot, totalling to about $3.7 billion. The payer refuted the report, saying, "[The] report is based on old data and is inaccurate and misleading — a disservice to seniors and an attack on the CMS payment system."

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