News: OIG audit says Tufts received $3.7 million in overpayments for high-risk diagnosis codes

CDI Strategies - Volume 16, Issue 8

An audit performed by the Office of Inspector General (OIG) of Tufts Health Plan, Inc. sampled 212 unique Medicare Advantage enrollee-years with high-risk diagnosis codes for the years 2015 though 2016. Only 54 of the 212 sampled validated HCCs, while the remaining 154 had diagnosis codes that were unsupported in the medical record.

Based on the sample result, the OIG estimates that Tufts received at least $3.7 million in net overpayments for high-risk diagnosis codes in 2015 and 2016.

The OIG recommends that Tufts repay the $3.7 million, as well as identify similar instances of noncompliance for the high-risk diagnoses included in the audit and repay that amount as well.

Tufts did not agree with the findings, stating that at least five enrollee-years should not have been included in the calculation of net overpayments because it had already submitted corrections to CMS. Tufts did not comment on the additional 154 errors.

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

Found in Categories: 
Denials & Appeals, Clinical & Coding