The audit, published Oct. 3, examined diagnosis codes Highmark submitted to CMS, and found 160 of 226 enrollee-years sampled did not comply with federal requirements.
CMS provides Medicare Advantage plans with monthly payments based on the risk status of enrollees. These risk statuses are calculated using diagnostic codes.
OIG recommended Highmark refund the $6.2 million in estimated overpayments. Highmark disagreed with the audit’s findings and recommendations, contesting OIG’s auditing and sampling methodologies.
OIG published similar audits of BlueCross BlueShield of Tennessee and Inter Valley Health Sept. 30.
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