Aetna may have received $25.5M in MA overpayments for 2015 and 2016, audit finds

Healthcare DIVE October 6, 2023
Emily Olsen

Medical records provided by the insurer didn’t support certain diagnosis codes, resulting in overpayments, according to an audit from the HHS’ Office of the Inspector General.

Dive Brief:

• Aetna received an estimated $25.5 million in Medicare Advantage overpayments for 2015 and 2016, according to an audit by the HHS’ Office of the Inspector General.
• The audit analyzed seven groups of diagnosis codes that were at a high risk of being miscoded and determined medical records didn’t support the codes for 155 of the 210 sampled enrollee-years, resulting in $632,070 in overpayments. Based on the sample results, the OIG extrapolated that Aetna received at least $25.5 million in overpayments for 2015 and 2016.
• The payer pushed back on the...

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