Today's Featured Story Anthem Refutes OIG Risk Score Review

by Lauren Flynn Kelly

In the second example in recent months of a Medicare Advantage insurer disputing the federal government’s method of identifying overpayments, a new HHS Office of Inspector General audit report limited its review to a group of diagnosis codes that it maintained are at a particular risk for being miscoded.

Conducted separately from CMS's contract-level Risk Adjustment Data Validation (RADV) audits that verify the accuracy of payments made to MA organizations, the recent findings are part of a series of audits in which OIG is reviewing the accuracy of diagnosis codes submitted to CMS. In a similar report released in April, OIG estimated that Humana Inc. received nearly $200 million in net overpayments for a contract serving approximately 485,000 enrollees.

In the May report, OIG recommended that Anthem repay the federal government $3.47 million for net overpayments related to a group of "high-risk" diagnosis codes, referring to certain disease categories that are prone to miscoding. OIG identified seven disease groups that have an elevated risk of being miscoded: acute stroke, acute heart attack, acute stroke and acute heart attack combination, embolism, vascular claudication, major depressive disorder, and potentially "mis-keyed" diagnosis codes.

OIG suggested that these coding inaccuracies were due to Anthem's inadequate procedures to detect and correct noncompliance. In a statement emailed to AIS Health, Anthem maintained that it complied with MA regulations when submitting the diagnosis codes in question and pointed out that OIG "did not identify any specific deficiencies in our programs through its audit."

Kirk Martindale, vice president of the data audit group within ATTAC Consulting Group, says it is imperative that MA plan sponsors have robust medical record review and audit procedures in place, particularly around those high-risk diagnosis code groups, to ensure that the codes they submit to CMS are accurate and can be backed by medical record documentation.

Similar to Humana, Anthem did not agree with OIG's findings and recommendations. Among its gripes, the insurer argued that the report: included inaccurate findings specific for major depressive disorder and embolism, relied on "sampling and review methodologies that are improperly skewed toward identifying 'overpayments,'" and used a lower confidence interval that is not as statistically sound as the higher interval used by CMS in its RADV audits.

OIG, however, disputed Anthem's characterization of its net overpayment calculations as skewed and biased and maintained that it used a statistically valid sampling methodology.

From RADAR on Medicare Advantage