News: OIG audit finds Anthem received $3.47 million in overpayments for specific diagnosis codes

More than $3 million could be owed by Anthem, according to an Office of Inspector General (OIG) audit. Anthem reportedly submitted unsupported diagnosis codes for “123 of the 203 enrollee-years,” for seven high-risk groups.

The OIG states that “these errors occurred because the policies and procedures that Anthem had to detect and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, were not always effected.” Based on the sample results, the OIG estimates that Anthem received at least $3.47 million of net overpayments for the high-risk diagnosis codes in the years 2015 and 2016.

The OIG recommends that Anthem refund the overpayments and identify similar instances of noncompliance for the high-risk diagnosis that may have occurred before or after the audit period. The OIG also recommends that Anthem “enhance its compliance procedures to focus on diagnosis codes that are high risk for being miscoded by (1) determining whether these diagnosis codes (when submitted to CMS for use in CMS’s risk adjustment program) comply with Federal requirements and (2) educating its providers about the proper use of these diagnosis codes.”

Editor’s note: The OIG audit can be found here. ACDIS coverage of other OIG audits can be found here.