OIG identifies $3.4 million in Medicare Advantage overpayments to Anthem

May 28, 2021

The HHS Office of the Inspector General (OIG) recently revealed CMS overpaid Anthem about $3.4 million in Medicare Advantage (MA) payments due to the payer failing to meet federal coding rules.

The overpayments were discovered as part of an audit of MA organizations where OIG focused on seven groups of high-risk diagnosis codes. The goal of the audit was to find whether the diagnosis codes Anthem submitted for use in CMS’s risk adjustment program complied with federal requirements.

The OIG sampled 203 unique enrollee-years with the high-risk diagnosis codes for which Anthem received higher payments for 2015 through 2016. The agency limited the review to the portions of the payments that were associated with those codes, which totaled $599,842.

When looking at the seven high-risk groups covered by the audit, most of the selected diagnosis codes that Anthem submitted to CMS for use in its risk adjustment program did not comply with the federal requirements. For 123 of the 203 enrollee-years, the diagnosis codes that Anthem submitted to CMS were not supported in the medical records and resulted in $354,016 of net overpayments for the 203 enrollee-years.

These errors occurred, OIG said, because the policies and procedures that Anthem had to detect and correct noncompliance were not always sufficient. Based on the sample results, OIG estimated that Anthem received at least $3.47 million of net overpayments for these high-risk diagnosis codes in 2015 and 2016.

The OIG recommended that Anthem refund the $3.47 million in overpayments to the federal government, and identify any similar instances of noncompliance that occurred before or after the audit period. The agency also wants the insurer to enhance its compliance procedures to focus on diagnosis codes that are at high risk of being miscoded.

Meanwhile, Anthem disagreed with OIG’s finding and recommendations and questioned the methodology and whether federal requirements were properly executed. Anthem also said the report reflected misunderstandings of the legal and regulatory requirements underlying the MA program.

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