The HHS Office of the Inspector General estimates $462 million in CMS overpayments to Medicare Advantage plans stemming from some unsupported acute stroke diagnosis codes.
In a May report, the OIG reviewed a sample of 97 MA beneficiaries. The entire sample had high-risk acute stroke diagnosis codes submitted by MA organizations that were not backed by medical records, the report said. This led to potential net overpayments amounting to $187,122. The overall estimate of $462 million extrapolates from that sample and encompasses the 2021 payment year.
Out of 773,999 MA enrollees with an acute stroke diagnosis code submitted during the 2020 service year, 240,401 had high-risk codes. MA organizations received more than $5 billion in payment for these enrollees, of which about $477 million was linked to the high-risk acute stroke diagnosis codes specifically.
This audit builds on 34 prior OIG reports, focused on high-risk diagnosis codes, for individual MA organizations. For nearly 97% of the 1,185 MA beneficiaries reviewed with an acute stroke diagnosis, diagnoses lacked support from medical records.
Because the audit spans many MA organizations, OIG did not call for CMS to claw back the money — but that may be requested through individual audits. OIG did advise CMS to establish a process to stop overpayments for these diagnosis codes, such as through a data filter to identify codes on physician records that do not have hospital documentation. CMS has not concurred with or denied OIG’s recommendations.
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