The agency recommends the payer refund the estimated overpayments to the federal government and review its compliance procedures.
Cigna-HealthSpring of Tennessee received $5.9 million in Medicare Advantage overpayments for 2016 and 2017, a report by the Office of Inspector General (OIG) found.
The audit sampled 279 unique enrollee-years with the high-risk diagnosis codes for which Cigna received higher payments and revealed that 195 of the enrollee-years did not have medical records that supported the diagnosis codes.
The sample resulted in $509,194 in overpayments, with OIG extrapolating that figure to estimate that the payer owes nearly six million over a two-year span.
"As demonstrated by the errors found in our sample, Cigna's policies and procedures to prevent, detect, and correct noncompliance with CMS's program requirements, as mandated by Federal regulations, could be improved," OIG stated.
OIG recommended that Cigna refund the $5.9 million of estimated overpayments back to the federal government and identify similar instances of noncompliance that happened before and after the audit period to refund any other potential overpayments.
Additionally, OIG asked the health insurer to examine its compliance procedures to find 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 update those protocols.
Cigna did not concur with OIG's recommendations or findings and claimed that that intent and design of the investigation was "contrary to Medicare Advantage regulations and the goal of payment accuracy audits."
Following Cigna's comments, OIG revised the number of enrollee-years in error from 201 to 195 and revised the estimated overpayments from $6.3 million to $5.9 million. However, the agency did not alter its recommendations.
The audit of Cigna is one of many OIG has recently conducted of Medicare Advantage plans, including a report on Humana that uncovered $34.4 million in overpayments in 2016 and 2017.
Jay Asser is the contributing editor for strategy at HealthLeaders.
OIG found 195 of 279 unique enrollee-years for Cigna did not have medical records that supported the high-risk diagnoses.
The sample resulted in $509,194 in overpayments and OIG extrapolated that amount to estimate $5.9 million in overpayments for 2016 and 2017.
Cigna did not concur with OIG's recommendations and findings, claiming the audit did not assess payment accuracy.