OIG audit finds $6.9M in MA overpayments made to Coventry

Coventry Health and Life Insurance Company collected nearly $7 million in net overpayments from the Medicare Advantage program because of improper coding practices, according to audit findings from the Office of Inspector General.

The audit of the Saint Louis, Missouri-based Medicare Advantage (MA) organization, which is owned by Aetna, is part of a series of audits in which the Office of the Inspector General (OIG) is reviewing the accuracy of diagnosis codes that MA organizations submitted to CMS.

OIG has identified 10 diagnoses at higher risk of being miscoded, leading to potentially higher payments to MA organizations because of the program's risk adjustment rules. These high-risk diagnoses include acute stroke, acute myocardial infarction, embolism, sepsis and pressure ulcer, as well as several types of cancer.

For the 10 high-risk groups covered in the audit, OIG found that most of Coventry's submissions for the selected codes did not comply with federal requirements.

Specifically, the diagnosis codes submitted by Coventry were not supported by medical records for 249 of 300 sampled enrollee years, which account for enrollees who map to more than one of the high-risk diagnoses or have high-risk diagnosis codes in their medical records for more than a year.

These miscoded cases alone resulted in $752,587 in net overpayments, OIG reported. Based on the sample, OIG estimated a total of $6.9 million in net overpayments to Coventry from 2018 to2019.

OIG said that "Coventry’s policies and procedures to prevent, detect, and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, could be improved."

The federal watchdog recommended that Coventry refund the federal government the $6,995,522 of estimated net overpayments, as well as identify any other potential instances of miscoding that could have resulted in MA overpayments.

Through CVS Health, which owns Aetna, Coventry said it disagreed with the audit's findings and the OIG's recommendations.

"[W]e believe OIG's Draft Report departs from clear and contrary Medicare guidance -- including from OIG itself -- and contributes to the false impression that MA plans are gaming the system," Patrick Jeswald, chief compliance officer of Medicare at CVS Health, wrote to OIG.

Jacqueline LaPointe is a graduate of Brandeis University and King's College London. She has been writing about healthcare finance and revenue cycle management since 2016.