News: Coventry Health Care received half a million dollars in overpayment, latest OIG audit finds

In its latest round of Medicare Advantage audits, the Office of Inspector General (OIG) found that Coventry Health Care of Missouri, Inc. received $548,852 in overpayments from the years 2014 through 2016.

In the audit, the OIG focused on six groups of high-risk diagnosis codes, aiming to determine whether selected diagnosis codes submitted by Coventry for use in CMS’ risk adjustment program complied with federal requirements. The OIG selected 275 unique enrollee-years with the high-risk diagnosis codes that Coventry received higher payments for through the audit period. The review was limited to the portions of the payments that were associated with these high-risk diagnosis codes, totaling $701,593.

The OIG found that 226 of the 227 enrollee-years selected did not comply with federal requirements as they were not supported in the medical record. This resulted in a net overpayment of $548,852.

The OIG recommends that Coventry refund the money, as well as perform an audit of their own for the diagnoses identified by the OIG to find any similar instances of improper coding. If additional improper instances are found, the OIG recommends Coventry refund those overpayments as well. The OIG also recommended Coventry enhance compliance procedures by educating providers about their documentation and determining if the audited diagnosis codes comply with federal requirements.

Coventry agreed that the majority of the reviewed diagnosis codes were not supported by the medical record and to refund $542,541. For the other findings that Coventry did not agree with, they submitted additional documentation for the OIG’s consideration. After reviewing the additional documentation and Coventry’s comments, the OIG revised the number of enrollee-years in error, changing the recommendation to refund overpayments from $584,005 in the draft report to the $548,852 stated in this final report.

Editor’s note: This OIG audit can be found here. Additional ACDIS coverage of the recent OIG audits can be found here.