This year, the U.S. Office of the Inspector General conducted an audit of insurer Aetna's Medicare Advantage program to ensure that selected diagnosis codes Aetna submitted to CMS for use in CMS' risk adjustment program complied with federal requirements.
The OIG looked at 210 unique enrollees with high-risk diagnosis codes that Aetna received higher payments for between 2015 and 2016.
The audit determined that most of the codes Aetna submitted to CMS for use in the adjustment program did not comply with federal regulations. On the basis of the sample, the OIG estimates that Aetna received at least $25.5 million in overpayments in the one-year period.
The OIG issued recommendations to Aetna, suggesting that the insurer refund the federal government the overpayments, determine potentially miskeyed diagnosis codes for enrollees who were not part of the audit, identify similar instances of noncompliance, and continue to examine and improve compliance procedures.
"Aetna did not concur with our recommendations or agree with our findings for five enrollee-years sampled. Aetna did not state whether it agreed or disagreed with our findings for the remaining enrollee-years. Aetna also disagreed with our audit methodology, medical record review process and use of extrapolation," the findings report, published Oct. 2, reads.