Anthem should return $3.47 million to CMS after finding that the insurer miscoded over half of sampled claims as high-risk that received greater reimbursement than they should have under the Medicare Advantage program.
The Indianapolis, In.-based insurer – who is ultimately responsible for providers to make sure medical records line up with diagnosis codes – was paid more for providing benefits to sicker enrollees that are associated with needing more health care resources than healthier enrollees. The Office of the Inspector General at HHS in its report focused on seven major conditions that are especially at-risk of miscoding, including acute stroke, acute heart attack, embolism and major depressive disorder.
The OIG classified individuals by their condition and payment, finding that in 123 of 203 cases, CMS overpaid because the diagnosis did not have supporting medical record documentation. The majority of claims that lacked evidence included acute heart attack, acute stroke and potentially mis-keyed diagnosis codes.
For instance, there were 19 cases of embolisms that were then risk-adjusted to receive higher payments. But in these cases, patients did not receive anticoagulant medications that are typically used to treat embolisms. Similarly, there were six cases of major depressive disorder diagnosis' that didn't have corresponding antidepressant prescriptions in their medical records. CMS says it bases these conclusions on discussions with medical professionals and data mining techniques to detect diagnosis' that are in error.
"The errors we identified occurred because the policies and procedures that Anthem had to detect and correct noncompliance with CMS's program requirements, as mandated by Federal were not always effective," the report states.
Anthem in its response to the OIG report questioned the code review and overpayment methodology. In a statement to Modern Healthcare, the insurer said it complies with Medicare Advantage regulations and that it has compliance procedures to check diagnosis codes with medical record information.
The OIG report is the latest in a series monitoring compliance of CMS' Medicare Advantage risk adjustment program. About 34% of Medicare payments in 2019 – or $273.8 billion – were for enrollees in MA. Under the program CMS pays sets base payments and then adds on additional bumps that up depending on how sick a patient is, mainly calculated through coding.
The OIG also recommends that Anthem educate its providers about properly using diagnosis codes, which Anthem says it already does. This report follows another in April of this year that found CMS also overpaid Humana because of similar issues, which that insurer also contested.