Health

OIG: CMS overpaid Anthem by nearly $3.5M in Medicare Advantage

A new Office of the Inspector General report shows that CMS overpaid Anthem by at least $3.47 million in Medicare Advantage in 2015 and 2016.

The Department of Health and Human Services OIG studied 203 unique enrollee-years to determine how the insurer submitted high-risk codes to the Centers for Medicare & Medicaid Services for reimbursement, according to the study.

The study found that $599,842 in payments overall were associated with these codes. Of that amount, $354,016 was associated with codes that were not supported by medical records, indicating overpayment.

Based on this sample, OIG estimates that $3.47 million in overpayments were made during the two-year study window.

RELATED: CMS may overpay Medicare Advantage plans by billions, study finds

OIG said that it found Anthem’s policies to detect noncompliance with reimbursement requirements were not always effectively used. 

The organization recommended that Anthem repay those amounts and conduct further audits to determine other potential instances of overpayment related to these codes. In addition, OIG said the insurer should enhance its compliance methods for high-risk diagnostic codes.

Anthem disagreed with the findings and recommendations, according to the report. The insurer did not agree with the methodology used in the analysis and disputed the findings for specific enrollee-years.

Anthem also said the “report reflected misunderstandings of legal and regulatory requirements underlying the [Medicare Advantage] program. OIG said it maintains its findings.

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