Under the Medicare Advantage program, CMS makes monthly payments to organizations according to a system of risk adjustment determined by enrollees’ health status. CMS is auditing providers’ medical records to ensure that the diagnostic codes used to determine a patient’s health status are supported and the resulting risk-adjusted payment is accurate.
CVS’ Aetna said the OIG may require it to refund payments to CMS if the risk-adjusted premiums are not supported in medical record data.
Aetna also said it expects the OIG to continue these types of audits.
Earlier this year, an OIG audit estimated that Humana received $197.7 million in overpayments because of unsupported risk scores for some of its beneficiaries.
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