Audits of BlueCross BlueShield of Tennessee and Inter Valley Health Plan found the organizations' Medicare Advantage plans received millions in overpayments as a result of diagnosis codes submitted to CMS that were not backed up by medical records.
CMS pays Medicare Advantage organizations monthly fees based on the health status of each enrollee. Organizations are paid more for providing benefits to enrollees who will likely need more expensive care based on health diagnoses.
The OIG audit of BCBST found most of the diagnosis codes submitted for nine diagnoses identified as high risk of miscoding were not in compliance with federal regulations. The OIG recommended the Chattanooga, Tenn.-based insurer repay the federal government $7.8 million based on the audit.
BCBST agreed to refund this amount, according to the audit. The insurer disagreed with some of the audit's findings and submitted additional documentation to back up some of the diagnosis codes.
Pomona, Calif.-based Inter Valley Health received around $5.3 million in overpayments as a result of not submitting diagnosis codes in compliance with federal regulations, according to the OIG.
The insurer disputes the OIGs audit methodology and did not concur with its recommendations to refund the federal government for overpayments.