The United States Department of Health and Human Services Office of Inspector General (HHS OIG) recently released results from its audit of Humana Health Plan, Inc. In the audit, HHS OIG was reviewing specific diagnosis codes that Humana submitted to the Centers for Medicare and Medicaid Services (CMS). Specifically, HHS OIG chose a stratified random sample of 240 unique enrollee-years with certain high risk diagnosis codes for which Humana received higher payments in 2017 and 2018. The agency limited the review to the portions of payments that were associated with the high-risk diagnosis codes, totaling $642,816.
In conducting the audit, HHS OIG found that for the eight high-risk groups reviewed under the audit, most of Humana’s submissions of the selected diagnosis codes to CMS for use in CMS’ risk adjustment program did not comply with federal requirements.
According to the report, for 202 of the 240 sampled enrollee-years, the diagnosis codes submitted to CMS by Humana were not supported by the medical records, resulting in $497,225 in overpayments. HHS OIG then estimated, based on the sample, that Humana received at least $13.1 million in overpayments for 2017 and 2018. Federal regulations limit the use of extrapolation in Risk Adjustment Data Validation audits for recovery purposes for payment years 2018 and forward. Therefore, HHS OIG reported the overall estimated overpayment but is only recommending a refund of $6.8 million (split as ($274,151 for the sampled enrollee-years from 2017 and an estimated $6,503,234 for 2018).
As noted above, HHS OIG recommended that Humana refund the federal government $6.8 million of the estimated overpayments and identify, for the specific high-risk diagnoses included in the report, similar instances of non-compliance that occurred before or after the audit period and refund any of those overpayments as well. HHS OIG further recommended that Humana examine its existing compliance procedures to identify areas where improvements can be made to ensure that diagnosis codes that are at high risk for being miscoded comply with federal requirements and take any additional steps that may help enhance those procedures.
Humana disagreed with some of the HHS OIG findings and all of the recommendations More specifically, Humana disagreed with the findings for 33 of the 2016 enrollee-years identified as errors in the draft report and provided additional information to HHS OIG. Humana also disagreed with the agency’s audit methodology and overpayment estimation methodology. After reviewing the additional data, HHS OIG reduced the number of enrollee-years identified as errors and revised the amount in the first recommendation, while maintaining the validity of the second and third recommendations.