Humana’s Louisiana business received at least $10.5 million in Medicare Advantage overpayments in 2017 and 2018, according to an audit report from HHS’ Office of Inspector General.
The audit, published in December, reviewed high-risk diagnosis codes including acute stroke, acute myocardial infarction, and several cancer categories. The agency found $553,049 in overpayments in its sample of 240 enrollee-years, which it used to estimate the health plan received at least $10.5 million in overpayments during the audit period.
Medical records did not support the submitted diagnosis codes for 218 of the 240 sampled cases. Many errors involved providers documenting a patient’s medical history of a condition rather than an active diagnosis.
Humana disagreed with all of the OIG’s findings and recommendations.
“OIG audit findings and recommendations do not represent final determinations by CMS,” a Humana spokesperson told Becker’s. “We look forward to working with CMS to address risk adjustment data accuracy consistent with the Court’s recent decision vacating and remanding CMS’s risk adjustment data validation rule. Humana has consistently called for CMS to audit every plan, every year using the right methodology that is consistent with the underlying principles of the Medicare Advantage model.”
The OIG recommended the company repay $5.5 million to the federal government, rather than the estimated $10.5 million, because federal law limits the use of extrapolation for recovery purposes to payment year 2018 and forward. According to the report, CMS will determine whether overpayment occurred and will recoup any overpayments if necessary.
