CMS paid in excess $ 3.4M in Medicare Advantage, says OIG

Innu must return $ 3.47 million to CMS after finding that the insurer has erred in more than half of the high-risk claims that they received a larger reimbursement than they should have in the Medicare Advantage program. .

The Indianapolis-based insurer, In. – which is ultimately responsible for providers to ensure that medical records align with diagnostic codes – has been paid more to provide benefits to sicker patients who are associated with needing more health resources than ‘insert healthier. The Office of the Inspector General to HHS in its report focused on seven main conditions that are particularly at risk for miscoding, including acute stroke, acute heart attack, embolism, and major depressive disorder.

The OIG classified the individuals by their situation and their payment, finding that in 123 of 203 cases, CMS paid more because the diagnosis lacked supporting medical records. Most of the claims that lacked evidence included acute heart attack, acute stroke and potentially misdiagnosed codes.

For example, there were 19 cases of emboli that were then adapted to the risk to receive higher payments. But in these cases, patients have not received anticoagulant medications that are typically used to treat embolism. Similarly, there were six cases of diagnoses of major depressive disorder ’that did not have corresponding antidepressant prescriptions in their medical records. CMS says it bases these findings on discussions with medical professionals and data mining techniques to detect diagnoses that are in error.

“The errors we identified occurred because the policies and procedures that Anthem had to address and correct the lack of compliance with CMS programming requirements, as mandated by Federal were not always effective,” the report says. .

Innu in his response to the OIG report discussed the revision of the code and the overpayment methodology. In a statement to Modern Healthcare, the insurer said it complies with Medicare Advantage regulations and that it has compliance procedures to verify diagnostic codes along with information from medical records.

The OIG report is the latest in a series of compliance monitoring of CMS ’Medicare Advantage risk regulation program. About 34% of Medicare payments in 2019 – or $ 273.8 billion – were for enrollment in MA. Under the CMS pay program it establishes basic payments and then adds additional balances depending on how sick a patient is, mainly calculated by coding.

The OIG also recommends that Anthem educate its suppliers on the correct use of diagnostic codes, which Anthem says it already does. This report follows another in April this year he found CMS also paid more Humana because of similar problems, which that insurer also disputed.

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