News: OIG audit claims SCAN Health Plan received $54.3 million in overpayments

CDI Strategies - Volume 16, Issue 6

SCAN Health Plan received nearly $55 million in overpayments for 164 unvalidated HCCs out of a 1,577 sample for 2015, according to an Office of the Inspector General (OIG) audit. The audit looked to verify diagnosis codes for risk adjustment.

According to the OIG, “these 164 unvalidated HCCs included 20 HCCs for which we identified 20 other HCCs for more and less severe manifestations of the diseases,” There were an additional 21 HCCs for which the medical records supported diagnosis codes that SCAN should have submitted to CMS but did not.

Because of this, the 200 samples enrollees should not have been based on 1,577 HCCs but instead 1,454 HCCS (1,413 validated HCCs plus the 20 other HCCs, plus the 21 additional HCCs). The OIG estimates that SCAN received at least $54.3 million in net overpayments for 2015 and recommends the health plan refunds the entire overpayment amount.

SCAN disagrees with the OIG findings, specifically noting the OIG independent medical review contractor “erred in its determinations by not validating certain HCCs.” SCAN additionally stated the OIG report was seriously flawed because of errors in the approaches used to identify the sample of enrollees for the audit.

After reviewing SCAN’s comments and additionally provided information, the OIG revised the number of unvalidated HCCs and, accordingly, the recommend refund for the final report.

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

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