The Office of Inspector General (OIG) on Monday said it sampled 270 unique enrollee-years and found Geisinger received higher payments for high-risk diagnosis codes for 2016 and 2017. The audit was limited to payments associated with the high-risk diagnosis codes, which totaled $706,678.
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Most of the diagnosis codes that Geisinger submitted to CMS didn’t comply with federal requirements, according of the audit report. OIG said that for 224 of the sampled enrollee-years, either the medical records provided didn’t support the diagnosis codes or Geisinger couldn’t locate the medical records to support the codes. The result was $566, 476 of net overpayments. Based on the sample results, OIG estimated that Geisinger received at least $6.5 million of net overpayments for 2016 and 2017.
The OIG recommends that the MA health plan:
- Refund Medicare the $566,476 of net payments
- Identify similar instance of noncompliance that occurred before and after the audit report and refund any overpayments
- Examine and improve existing compliance procedures
Geisinger disagreed with all the OIG’s findings and recommendations, especially its initial one in the draft report that it should refund $6.5 million in estimated net overpayment. However, the health plan did not specifically disagree with any of the findings for the sampled enrollee-years identified in the draft report as not having medical records to support the associated diagnosis codes. Geisinger stated that it would delete unsupported codes found for the 224 sampled enrollee-years during the audit.
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After reviewing Geisinger's comments, the OIG maintains its findings were valid. The only change it made was to request a refund of the net overpayments for the sampled enrollee years because CMS has updated regulations for audits in the risk adjustment program to specify that extrapolated overpayments could only be recouped beginning with payment year 2018.