News Briefs: April 26, 2021

In a Medicare Advantage (MA) compliance audit[1] of diagnosis codes submitted to CMS by Humana Inc., OIG determined that “Humana did not submit some diagnosis codes to CMS for use in the risk adjustment program in accordance with Federal requirements.” As a result, “we estimated that Humana received at least $197,720,651 in net overpayments for 2015,” OIG said, and suggested that Humana refund that amount to the federal government and enhance its policies and procedures. OIG audited a stratified random sample of 200 enrollees in Humana’s MA plan, and Humana turned over medical records to support 1,525 Hierarchical Condition Categories (HCCs) associated with the enrollees. Although most of the diagnosis codes that Humana submitted were supported in the medical records, “the remaining 203 HCCs were not validated and resulted in overpayments. These 203 unvalidated HCCs included 20 HCCs for which we identified 22 other, replacement HCCs for more and less severe manifestations of the diseases,” OIG said. “Second, there were an additional 15 HCCs for which the medical records supported diagnosis codes that Humana should have submitted to CMS but did not. Thus, the risk scores for the 200 sampled enrollees should not have been based on the 1,525 HCCs. Rather, the risk scores should have been based on 1,359 HCCs.” Humana disagreed with OIG’s findings and its recommendations.

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