OIG: Medicare Advantage Overpaid Anthem $3.5M

Anthem disputed the findings and rejected the recommendations in its rebuttal of the report.

Federal auditors are calling for Anthem Community Insurance Company, Inc., to refund nearly $3.5 million in alleged upcoded overpayments submitted to and paid for by Medicare Advantage.

The audit, conducted by the Office of the Inspector General at the Department of Health and Human Services, examined 203 unique enrollee-years with the high-risk diagnosis codes for which Anthem received more money from 2015 to 2016.

"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," OIG said.

"These errors occurred because the policies and procedures that Anthem had to detect and correct noncompliance with CMS's program requirements, as mandated by Federal regulations, were not always effective," the audit said. "On the basis of our sample results, we estimated that Anthem received at least $3.47 million of net overpayments for these high-risk diagnosis codes in 2015 and 2016."

In addition to the refund, OIG recommended that Anthem similar instances of noncompliance that occurred before or after the audit period and refund any additional payments and enhance its compliance procedures to focus on diagnostic codes that are at high risk of being misused.

Anthem disputed the findings and recommendations in its rebuttal of the report, asked OIG to withdraw the demand for an extrapolated $3.47 million payment, and instead conduct more audits beyond the 203 samples and make any repayments based on those findings.

Anthem Responds

In a statement emailed Wednesday to HealthLeaders, Anthem said it "complied with applicable Medicare Advantage regulations, including those set forth by CMS and reviewed in this audit by the OIG for HHS."

"The OIG report acknowledges that Anthem and CIC had compliance procedures in place to determine whether submitted diagnosis codes to calculate risk-adjusted payments were supported by medical record documentation," Anthem said.

"The OIG also acknowledged that Anthem had procedures to compare diagnosis codes from specific claims to the diagnoses that were documented on the associated medical records, make corrections as appropriate, and provide guidance on how its reviewers should address certain high-risk diagnoses. It further found that Anthem's compliance procedures included outreach to help educate our providers. The OIG did not identify any specific deficiencies in our programs through its audit."