OIG REPORT: Medical Advantage Compliance - Independent Health Association, Inc.

 From the email Office of Inspector General (OIG) newsletter covering 2024 Nationwide Health Care Fraud Enforcement Action:

The OIG reviewed Independent Health Association, Inc. (IHA) (Contract H3362). OIG concluded that most of the selected diagnosis codes submitted by IHA were submitted to the Centers for Medicare & Medicaid Services (CMS) for use in CMS’s risk adjustment program did not comply with Federal requirements. This resulted in $646,217 in overpayments

The audit covered the enrollee-years for 2016 and 2017. OIG performed audit work from September 2019 through June 2024. 

The OIG concludes that as they found errors in their sample, IHA’s policies and procedures to prevent, detect, and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, could be improved.

IHA disagreed with some of the findings, specifically the findings for 17 of the 232 enrollee-years. They did not agree with the audit methodology, use of extrapolation and standards for data accuracy. They also did not agree with the OIG’s recommendation that it refund overpayments. 

The high-risk diagnosis codes included:

Acute stroke

Acute heart attack

Embolism

Lung cancer

Breast cancer

Colon cancer

Prostate cancer

Potentially mis-keyed diagnosis

The potentially mis-keyed diagnosis are covered in Appendix F of the full report. An example of mis-keying diagnosis is entering the ICD-9 code of 250.00 Type 2 diabetes instead of a diagnosis of 205.00 acute myeloid leukemia.   

The full report is available here https://oig.hhs.gov/documents/audit/9922/A-07-19-01194.pdf

Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to take the place of either the written law or regulations.  The information presented herein is for general informational purposes only and is accurate as of the date of publication.