Healthfirst received $5.2M in overpayments, OIG audit finds

An HHS Office of Inspector General audit of seven Healthfirst Health Plan high-risk groups found several diagnosis codes submitted for use in CMS’ risk adjustment program did not meet federal guidelines, resulting in more than $516,000 in overpayments within the sample. 

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The office studied 240 unique enrollee-years, finding 151 included codes not supported by member medical records. 

Using that data from the sample, the office estimates that Healthfirst received $5.2 million in net overpayments between 2015 and 2016. 

The Office of Inspector General recommended Healthfirst refund the $5.2 million overpayments, identify further noncompliance based on the outlined erroneous codes, and improve its coding to mitigate future errors. 

According to a Jan. 5 report, Healthfirst objected to the recommendations, insisting it only pay the $516,000 found in the sample and not the $5.2 million estimate because the office “lacked the authority to use extrapolation.” 

The Office of Inspector General found its recommendations and findings to be valid even after reviewing Healthfirst’s objections. 

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