Some diagnosis codes used to obtain payments that Geisinger Health Plan submitted to the Centers for Medicare & Medicaid Services (CMS) did not comply with federal requirements, according to a draft report released Monday by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG).
OIG said that based on estimates Geisinger received at least $6.5 million in overpayments for 2016 and 2017, but added that Geisinger disagreed with almost all findings outlined in the report.
Under the Medicare Advantage (MA) program, CMS makes monthly payments to healthcare organizations according to a system of risk adjustment that depends on the health status of each enrollee. These organizations are paid more for providing benefits to enrollees with diagnoses associated with more intensive use of healthcare resources than to healthier enrollees who would be expected to require fewer healthcare resources.
To determine the health status of enrollees, Medicare Advantage-affiliated organizations collect diagnosis codes from their providers and submit the codes to CMS. Some diagnoses are at higher risk for being miscoded and may result in overpayments from CMS, OIG noted.
“Based on an audit involving nine high-risk groups … most of the selected diagnosis codes that Geisinger Health Plan … submitted to the Centers for Medicare & Medicaid Services (CMS) for use in CMS's risk adjustment program did not comply with federal requirements,” OIG said.
OIG sampled 270 unique enrollee-years with the high-risk diagnosis codes for which Geisinger received higher payments for 2016 and 2017. For 224 of the 270 sampled enrollee-years, either the medical records that Geisinger provided did not support the diagnosis codes, or Geisinger could not locate the medical records to support the diagnosis codes, resulting in $566,476 of net overpayments, OIG said.
“As demonstrated by the errors found in our sample, Geisinger's policies and procedures to prevent, detect, and correct noncompliance with CMS's program requirements could be improved,” it said, adding, “On the basis of our sample results, we estimated that Geisinger received at least $6.5 million of net overpayments for 2016 and 2017.”
OIG recommended that Geisinger refund to the federal government the $566,476 of net overpayments and identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before and after the audit period so that any resulting overpayments could be refunded. The agency also recommended that “Geisinger examine its current compliance procedures to identify areas where improvements can be made to ensure that diagnosis codes that are at high risk for being miscoded comply with federal requirements and take the necessary steps to enhance those procedures.”
OIG noted that Geisinger disagreed with all findings and recommendations. “Specifically, Geisinger disagreed with our first recommendation in the draft report that it should refund $6.5 million in estimated net overpayments, and disagreed with our second and third recommendations,” OIG said.
However, according to OIG, Geisinger did not specifically disagree with any of the findings for the sampled enrollee-years identified in the draft report as not having medical records to support the associated diagnosis codes. Additionally, Geisinger said it would delete unsupported codes found for the 224 sampled enrollee-years during our audit, OIG said.