Anthem allegedly received $3.4 million in overpayments for high-risk Medicare Advantage members who should not have been classified as such in 2015 and 2016, the Office of Inspector General for HHS said in an audit.
The payer allegedly submitted inaccurate diagnosis codes for MA enrollees, yielding a higher payout to the Indianapolis-based insurer as patients with higher risk scores, or those who tend to be sicker, result in a higher monthly payment from the federal government.
OIG wants Anthem to refund the $3.4 million in estimated overpayments and return any additional funds for similar instances of noncompliance that occurred outside of the latest two-year audit window.
The watchdog zeroed in on seven conditions designated as high-risk areas, including strokes and heart attacks. OIG obtained only a sample of patients diagnosed with these high-risk conditions and then used the sample results to estimate the overall share of overpayments. The audit found that in most instances Anthem was out of compliance.
"Most of the selected diagnosis codes that Anthem submitted to CMS for use in CMS's risk adjustment program did not comply with Federal requirements," the audit found.
For example, the audit found one instance in which an acute stroke diagnosis was recorded but the records and notes from an inpatient admission shows an MRI that was negative for a stroke.
Anthem disagreed with OIG's findings, according to a letter from the company contained in the report. It took issue with the methodology used to determine the overpayments, characterizing it as "skewed." Anthem also argued that it should not include alleged overpayments that OIG could not reconcile.
Anthem isn't the only payer that has been dinged for MA overpayments. It's a serious concern among federal regulators who say insurers should not "game the system."
Recently, OIG found Humana netted nearly $200 million in MA overpayments. And last year both Cigna and Anthem were sued by the Department of Justice for similar practices.
MA enrollment continues to grow as seniors choose to stick with the private insurance plans they're used instead of selecting traditional Medicare coverage.
MA organizations were paid nearly $274 billion in 2019, representing 34% of all Medicare payments in a single year.