News: Healthfirst Health Plan, Inc., received $5.2 million in overpayments for seven high-risk diagnoses, OIG says

The Office of Inspector General (OIG) recently conducted an audit of Healthfirst Health Plan, Inc., focused on seven groups of high-risk diagnosis codes to determine whether the organization complied with federal requirements when submitting the audited codes. According to the OIG’s findings, Healthfirst Health Plan, Inc., failed to comply on the majority of the examined records.

To conduct the audit, the OIG sampled 240 enrollee-years with the high-risk diagnosis codes for which Healthfirst Health Plan, Inc. received higher payments for 2015-2016. Their review was limited to the portion of the payments associated with the codes under examination, totaling $787,928. According to the OIG, the seven high-risk areas audited were:

1. Acute stroke
2. Acute heart attack
3. Acute stroke and acute heart attack combination
4. Embolism
5. Vascular claudication
6. Major depressive disorder
7. Potentially mis-keyed diagnosis codes

The findings revealed that the documentation Healthfirst Health Plan, Inc., submitted for 155 out of the 240 enrollee-years examined did not support the code assignment. These errors resulted in $516,509, according to the audit findings. Based on the sample results, the OIG estimated that Healthfirst Health Plan, Inc. received at least $5.2 million in net overpayments for these high-risk diagnosis codes in 2015-2016.

The OIG recommended that Healthfirst Health Plan, Inc.:

• Refund the government the $5,221,901 of estimated net overpayments
• Identify similar instances of noncompliance that occurred during the audit period that weren’t included in the sample and resulting overpayments
• Continue its examination of existing compliance procedures to identify areas where improvements can be made to ensure that diagnosis codes comply with federal requirements and take the necessary steps to improve those procedures

While Healthfirst Health Plan, Inc., did not dispute the OIG’s findings in the audit, they did disagree with their recommendations. Among other objections, Healthfirst Health Plan, Inc., requested that the OIG limit their recommended recovery to the overpayments identified in the sample and not those extrapolated value, and they stated that the OIG does not have the authority to use extrapolation to recommend a repayment.

Editor’s note: To read the full OIG report, click here. To read about other OIG audits and activity, click here.