News: OIG says Essence overpaid the government an estimated $158,000 for stroke, major depressive disorder, OIG says

Essence Healthcare Inc., a health maintenance organization (HMO) with a Medicare contract based in Missouri and Southern Illinois, submitted incorrect claims for acute stroke and major depressive disorder that did not comply with federal requirements, resulting in $158,000 in overpayments to Medicare Advantage (MA), according to an Office of Inspector General (OIG) audit.

The OIG reviewed 218 unique enrollee-years with high-risk ICD-10-CM codes billed for acute stroke and major depressive disorder between 2012 and 2014. It found that for 75 of the 218 enrollee-years, diagnosis codes were not supported in the medical records or could not be supported because Essence couldn’t locate the medical records, according to Revenue Cycle Advisor. Specifically, of the claims submitted with high-risk ICD-10-CM codes for acute stroke found that:

• For 46 enrollee-years, the provider should have documented a history of stroke ICD-10-CM code instead of an acute stroke code.
• For one enrollee-year, a noninpatient provider incorrectly documented an ICD-10-CM code that had been ruled out.  
• For one enrollee-year, Essence could not locate the medical record in which the ICD-10-CM code of acute stroke originated.

For claims submitted with high-risk ICD-10-CM codes for major depressive disorder the OIG found that:

• For 23 enrollee-years, the provider should have documented a diagnosis code for a less severe form of depression, instead of one for major depressive disorder.
• For four enrollee-years, Essence could not locate the medical records from which the diagnosis code for major depressive disorder originated.

The errors occurred because Essence’s policies to detect and correct noncompliant Medicare claims were not always effective,  the OIG says, and recommended  Essence refund the $158,904 in overpayments. Additionally, the OIG recommends that Essence:

• Enhance its policies and procedures for identifying noncompliance with federal requirements for all diagnosis codes used to calculate risk-adjusted payments.
• Identify instances of noncompliance that occurred during the audit period but were not included in the sample, as well as instances of noncompliance that occurred outside of the audit period.

Editor’s note: This article originally appeared in Revenue Cycle Advisor. To read the OIG’s report, click here. To read about other recent OIG activities, click here.