The Office of Inspector General (OIG) recently released the findings of recent Medicare Advantage plan compliance audits of specific diagnoses codes. Medicare overpaid all three plans.
Here’s a summary of what the OIG audits found as part of its series of audits of high-risk diagnostic codes that Medicare Advantage organizations submitted to the Centers for Medicare & Medicaid Services (CMS) for use in its risk adjustment program.
UCare Minnesota owes $4.7M
UCare, a Minneapolis-based plan, received approximately $1.7 billion in 2018 and 2019 to provide coverage to its 102,484 enrollees. The OIG audit focused on a stratified random sample of 294 enrollee years and payments associated with 10 groups of high-risk diagnosis codes: Acute stroke, acute myocardial infarction, embolism, lung cancer, breast cancer, colon cancer, prostate cancer, ovarian cancer, sepsis, and pressure ulcer.
OIG found most of the selected diagnoses codes submitted did not comply with federal requirements. Only 40 of the sampled enrollee years were validated; the medical records for the remaining 254 enrollee years did not support the diagnosis codes. The result was $869,498 in net overpayments. Based on the sample results, OIG estimates that the Medicare Advantage received at least $4.7 million in net overpayments for 2018 and 2019.
The watchdog recommended that UCare Minnesota should refund Medicare the $4.7 million, identify similar instances of noncompliance before or after the audit period and refund any resulting overpayments, and review its existing compliance procedures to identify areas for improvement. UCare Minnesota disagreed with some of the findings and all of the OIG recommendations.
Blue Care Network of Michigan owes $3.4M
The Detroit-based plan provided coverage to 89,889 enrollees as of December 2018. The organization received $1.7 billion to provide coverage to its enrollees during the audit period of 2017 and 2018.
The OIG audit focused on a stratified random sample of 210 enrollee years and seven groups of high-risk codes: Acute stroke, acute myocardial infarction, embolism, lung cancer, breast cancer, colon cancer, and prostate cancer. The medical records for 192 of the sampled enrollee years did not support the diagnoses codes submitted and resulted in $542,162 in overpayments. Based on the sample results, OIG estimated that Blue Care Network of Michigan received at least $6.4 million in overpayments for 2017 and 2018. However, because federal regulations limit extrapolation in Risk Adjustment Data Validation audits to payment year 2018 and forward, OIG recommends that the Medicare Advantage plan refund $3.4 million in overpayments.
In addition, OIG recommends that the plan identify similar instances of noncompliance that occurred before or after the audit period and refund any resulting overpayments to Medicare. It also suggests the plan review its compliance procedures and identify areas of improvement.
Blue Care Network of Michigan didn’t agree with the OIG findings or recommendations and said that the watchdog has a “sampling bias inherent in this audit” and has “significantly misrepresented the degree of improper payments” of other audits of Medicare Advantage organizations.
Triple-S Advantage, Inc. owes nearly $300K
The Medicare Advantage organization, which is based in San Juan, Puerto Rico, received $1.5 billion to provide coverage to its 97,158 enrollees for 2016 and 2017. The audit focused on those two years and a stratified random sample of 281 enrollee years and nine groups of high-risk diagnoses codes: Major depressive disorder, vascular claudication, acute stroke, colon cancer, breast cancer, prostate cancer, acute heart attack, embolism, and lung cancer.
The OIG found that the diagnoses codes for 204 of the sampled enrollee years were not supported by the medical records and resulted in $296,758 in overpayments. The watchdog recommends that Triple-S refund the overpayment, identify similar instances of noncompliance that occurred before or after the audit period and refund any resulting overpayments to Medicare, and review its compliance procedures to identify areas for improvement. Triple-S did not agree with all of the findings and recommendations.