An HHS Office of Inspector General audit found SCAN Health Plan received $54.3 million in overpaid Medicare Advantage claims.
The audit analyzed 200 enrolled and 1,577 associated hierarchical condition categories from 2015. The office found 164 of the HCCs were not supported by medical records provided by SCAN Health Plan, which is based in California.
Due to the error, the payer's 2015 risk score should have been calculated based on 1,454 HCCs. The difference resulted in the estimated $54.3 million in overpayments.
SCAN Health Plan contested the audit and said many of the HCCs were unvalidated. OIG reviewed its findings and stood by its estimation.