Did you know our Compliance Risk Analyzer (CRA) can identify high risk procedures that are likely to trigger an audit?
Watch the CRA explainer video by Healthcare Compliance Pros.
Wednesday, May 31, 2023 | In The News
Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Keystone Health plan East, Inc. (Contract H2952) Submitted to CMS
Today, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released the complete report and a report in brief.
Why OIG Did This Audit
Under the Medicare Advantage (MA) program, the Centers for Medicare & Medicaid Services (CMS) makes monthly payments to MA organizations according to a system of risk adjustment that depends on the health status of each enrollee. Accordingly, MA organizations are paid more for providing benefits to enrollees with diagnoses associated with more intensive use of health care resources than to healthier enrollees who would be expected to require fewer health care resources.
To determine the health status of enrollees, CMS relies on MA organizations to collect diagnosis codes from their providers and submit these codes to CMS. Some diagnosis codes are at a higher risk for being miscoded, which may result in overpayments from CMS.
For this audit, the OIG reviewed one MA organization, Keystone Health Plan East. The objective was to determine whether selected diagnosis codes that Keystone submitted to CMS for use in CMS's risk adjustment program complied with Federal requirements.
How OIG Did This Audit
The OIG sampled 270 unique enrollee conditions and payment years (enrollee-years) with the high-risk diagnosis codes for which Keystone received higher payments for 2016 and 2017. The department limited our review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $746,012.
What OIG Found
With respect to the nine high-risk groups covered by our audit, most of the selected diagnosis codes that Keystone submitted to CMS for use in CMS's risk adjustment program did not comply with federal requirements. Specifically, for 205 of the 270 sampled enrollee-years, the medical records that Keystone provided did not support the diagnosis codes and resulted in $550,391 in overpayments. As demonstrated by the errors in the sample, Keystone's policies and procedures to prevent, detect, and correct noncompliance with CMS program requirements could be improved. On the basis of the OIG's sample results, they estimated that Keystone received at least $11.3 million in overpayments for 2016 and 2017.
What OIG Recommends and Keystone Comments
HHS Office of Inspector General (OIG) recommends that Keystone must do the following action-items:
- Refund to the Federal Government the $550,391 for overpayments;
- Identify, for the high-risk diagnoses included in the report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government;
- Continue its examination of existing compliance procedures to identify areas in which improvements can be made to ensure diagnosis codes that are at high risk for being miscoded comply with Federal requirements (when submitted to CMS for use in CMS's risk adjustment program) and take the necessary steps to enhance those procedures;
- Ensure that it collects, for audits of risk adjustment data, medical records that comply with CMS requirements.
In written comments on their draft report, Keystone concurred with the OIG's third and fourth recommendations but did not fully agree with the OIG's findings and the first and second recommendations. Keystone provided additional information related to medical records it previously gave us. After reviewing Keystone's comments and the additional information provided, the OIG revised the number of enrollee-years in error from 207 to 205 for this final report.
After the OIG issued their draft report, CMS updated regulations for audits in its risk adjustment program to specify that extrapolated overpayments could only be recouped beginning with payment year 2018. Because the OIG's audit period covered payment years 2016 and 2017, the department revised their first recommendation to specify a refund of only the overpayments for the sampled enrollee-years. The OIG has made no changes to their other recommendations, while maintaining that their methodologies were reasonable and properly executed.
For more information, you can search for files under: Centers for Medicare and Medicaid Services.
Originally published from the by oig.hhs.gov, "Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Keystone Health Plan East, Inc. (Contract H3952) Submitted to CMS." Viewed 06/02/2023.