The headline from HHS OIG is that in 2021 CMS potentially overpaid Medicare Advantage (MA) organizations $462 million based on certain unsupported acute stroke diagnosis codes.

But the equivalent of a flashing red light in the report is that the Office of Inspector General reviewed MA organizations’ submissions for 97 individuals enrolled in a coordinated care or private fee-for-service MA plan and found that for all 97, “the high-risk acute stroke diagnosis codes that MA organizations submitted to CMS were not supported by the medical records associated with the physician data records containing the diagnoses.”

A perfect 97 for 97.

Background

OIG said CMS makes monthly payments to MA organizations according to a system of risk adjustment that depends on the demographic characteristics and health status of each enrollee.

“Accordingly, MA organizations are paid more for providing benefits to enrollees whose diagnoses are associated with more intensive use of healthcare resources relative to healthier enrollees, who would be expected to require fewer healthcare resources,” OIG said.

To determine the health status of enrollees, CMS relies on MA organizations to collect diagnosis codes from their providers and submit these codes to CMS.

“Some diagnoses are at higher risk for miscoding, which may result in overpayments from CMS. Previous OIG audits of specific MA organizations have identified acute stroke diagnosis codes submitted on physician data records without an acute stroke diagnosis on an inpatient or outpatient hospital data record during the same service year as a high-risk area for overpayment,” the examiners said.

Remedy

To remedy the perfect 97 for 97 discovery, OIG said it made one recommendation to CMS to implement a procedure to prevent overpayment to MA organizations but noted that CMS did not agree or disagree with its proposal.

Read the recommendation and full report here.

Comments or questions? Contact Patrick Connole at pconnole@parkplacelive.com.