News: OIG audit targets high-risk diagnosis codes, found $3.3 million in overpayments

Between 2015 and 2016, Peoples Health Network received about $3.3 million in overpayments, according to a recent audit conducted by the Office of Inspector General (OIG). The OIG estimated this amount from the diagnosis codes submitted by Peoples Health Network from high-risk groups, JustCoding reported.

Using data mining techniques and discussions with medical professionals, the OIG focused on seven groups of high-risk diagnosis codes based on the diagnoses that were more likely to be miscoded. These high-risk groups include the following:

• Acute stroke
• Acute heart attack
• Acute stroke and acute heart attack combination
• Embolism
• Major depressive disorder
• Vascular claudication
• Potential misdiagnosis (defined by the OIG as when a patient received multiple diagnoses for a condition but received only one—possibly mis-keyed—diagnosis for an unrelated condition)

The OIG selected 242 enrollee-years with high-risk diagnoses codes in the audit period that People Health Network received higher payments for, totaling $712,200, and the consequent review showed a notable discrepancy. Of the 242 enrollee-years selected, 144 were not supported in the medical record and so did not comply with federal requirements, resulting in a net overpayment of $412,938.

Based on these findings, the OIG recommended Peoples Health Network refund $3.3 million in overpayments to Medicare, identify similar instances and refund any other overpayments found, and identify where improvements can be made in its compliance procedures to better comply with federal requirements. Peoples Health Network did not agree with any of the OIG’s recommendations.

Editor’s note: To read JustCoding’s coverage of this story, click here. To read the OIG report, click here.