More Medicare Advantage fraud? Aetna received $25.5M in overpayments, says HHS
According to a HHS audit, medical records provided by the health insurer didn’t support certain diagnosis codes, similarly to Cigna’s lawsuit culminating in the insurer's agreement last week to pay $172 million to resolve allegations.
A recent HHS audit estimated that Aetna received an estimated $25.5 million in Medicare Advantage overpayments for 2015 and 2016.
The audit, conducted by the U.S. Department of Health and Human Services’ Office of Inspector General, analyzed seven groups of diagnosis codes that were at a high risk of being miscoded. Inspectors determined medical records didn’t support the codes for 155 of the 210 sampled enrollee-years, resulting in $632,070 in overpayments. Based on the sample results, inspectors concluded that Aetna received at least $25.5 million in overpayments for 2015 and 2016.
Last week, diagnostic codes were also at the center of a lawsuit against Cigna, with the insurer agreeing to pay $172 million to resolve allegations that it submitting false Medicare Advantage diagnostic codes.
In the HHS report of Aetna, the inspector general’s office recommended four measures for health insurer to take:
- “Refund to the federal government the $632,070 of overpayments;
- “Determine for the remaining 159 enrollee-years in the potentially mis-keyed diagnosis code high-risk group not reviewed as part of this audit whether the medical records in each case support the diagnosis for the unrelated condition and refund any resulting overpayments to the federal government;
- “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
- “Continue to examine and improve its compliance procedures.”
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Under the Medicare Advantage program, the Centers for Medicare & Medicaid Services makes monthly payments to plans based on a risk-adjustment system that pays more when enrollees are sicker and could require additional health-care resources. However, researchers and regulators have raised red flags about government overpayments to Medicare Advantage plans, arguing associated costs could jeopardize the entire Medicare program. A report by the USC Schaeffer Center for Health Policy and Economics in June found overpayments could reach more than $75 billion this year as a result of favorable selection of healthier beneficiaries, coding intensity and quality bonuses.
Aetna disagreed with the audit’s approach and recommendations. Patrick Jeswald, vice president and chief compliance officer for Medicare at CVS Health, responded that there were “numerous flaws” with the OIG’s methodology and its approach to the medical record review.
“The methodology’s flaw conflicts with a fundamental assumption of the risk-adjustment system,” he said. “The overreporting of some diagnosis codes offsets the underreporting of others, which achieves overall payment accuracy.”