Excellus BlueCross BlueShield received an estimated $5.4 million in Medicare Advantage overpayments in 2017 and 2018, according to an audit from HHS' Office of Inspector General.
The audit results were published July 10 and sampled 210 enrollee-years for seven high-risk diagnosis codes. OIG's audit could not validate 202 enrollee-years, resulting in $479,487 in overpayments.
Using the sample results, CMS estimates Excellus received $5.4 million in overpayments for 2017 and 2018. The agency only recommends a refund of $3.1 million because of a February risk adjustment rule that limits audits to contracts dated from payment year 2018 and forward.
CMS is also recommending the payer identify and refund any other similar overpayments that may have occurred, and continue monitoring and enhancement of its compliance procedures.
Excellus disagreed with CMS' recommendations and said its diagnosis codes were supported by medical records. It also did not agree with the audit's methodology, use of extrapolation, standards for data accuracy, or medical record review process. Excellus did not directly agree or disagree with the findings for the remaining 200 enrollee-years.|