The office studied 240 unique enrollee-years, finding 151 included codes not supported by member medical records.
Using that data from the sample, the office estimates that Healthfirst received $5.2 million in net overpayments between 2015 and 2016.
The Office of Inspector General recommended Healthfirst refund the $5.2 million overpayments, identify further noncompliance based on the outlined erroneous codes, and improve its coding to mitigate future errors.
According to a Jan. 5 report, Healthfirst objected to the recommendations, insisting it only pay the $516,000 found in the sample and not the $5.2 million estimate because the office “lacked the authority to use extrapolation.”
The Office of Inspector General found its recommendations and findings to be valid even after reviewing Healthfirst’s objections.
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