Coventry Health and Life Insurance Co., an Aetna subsidiary, received an estimated $6.9 million in Medicare Advantage overpayments, an audit published by HHS’ Office of Inspector General June 5 found.
The government watchdog reviewed a sample of diagnosis codes Coventry submitted between 2018 and 2019. OIG identified $752,587 of overpayments in its sample. Extrapolating from the sample, OIG estimated Coventry received $6.9 million in overpayments in 2018 and 2019.
Aetna acquired Coventry Health and Life Insurance Co. in 2013.
OIG recommended Aetna refund the government the estimated $6.9 million, and that the company identify any similar instances of noncompliance after the audit period. The watchdog also recommended Aetna identify areas where it could improve compliance with federal rules.
Aetna disagreed with the OIG’s recommendations, and disputed some of the audit’s findings. The company stated the OIG’s audit methodology violated “key requirements of the MA program.”
“We are committed to our compliance with CMS regulations and have an effective compliance program. We respectfully disagree with the conclusions of the OIG’s Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Coventry Health (Contract H1608) submitted to CMS,” Aetna said in a statement shared with Becker’s. “OIG applied highly specific targeting to identify samples to review and its findings are not representative of our overall submissions to CMS or the strength of our compliance programs.”
In May, CMS said it plans to ramp up audits of MA plans. The agency plans to audit every plan annually for potential overpayments. Currently, the agency audits around 60 plans each year.
MA plans are paid by the federal government based on enrollees’ health status. Sicker enrollees receive higher reimbursement.
CMS conducts risk-adjustment data validation audits to confirm the diagnoses MA organizations bill the federal government for are supported by health records. The Medicare Payment and Advisory Commission estimates MA plans receive up to $43 billion in overpayments from diagnoses not backed by medical records each year.
