Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Peoples Health Network (Contract H1961) Submitted to CMS

I thought this article that just came out might be of interest: Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Peoples Health Network (Contract H1961) Submitted to CMS A-06-18-05002 05-25-2022 (hhs.gov)

The very brief headline is that the Medicare Advantage plan (Peoples Heath Network – a United Healthcare company) was audited by the OIG for the risk adjusting diagnoses that they submitted.  Of the 242 unique enrollee-years that were audited, 98 had validated medical records that supported the HCC (Hierarchical Condition Categories) diagnoses submitted.  The other 144 unique enrollee-years diagnoses were not supported by the medical records, because Peoples Health was not able to locate the medical records.

The OIG is recommending “that Peoples Health (1) refund to the Federal Government the $3.3 million in overpayments; (2) identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government; and (3) enhance its existing compliance procedures to identify areas where 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.”

Please forward this to anyone else who may be interested.

Sheryn Honest, MBA, MLS, CHCO, CPC

Principal

The Honest Approach