Becker's Healthcare October 12, 2023
This year, the U.S. Office of the Inspector General conducted an audit of insurer Aetna’s Medicare Advantage program to ensure that selected diagnosis codes Aetna submitted to CMS for use in CMS’ risk adjustment program complied with federal requirements.
The OIG looked at 210 unique enrollees with high-risk diagnosis codes that Aetna received higher payments for between 2015 and 2016.
The audit determined that most of the codes Aetna submitted to CMS for use in the adjustment program did not comply with federal regulations. On the basis of the sample, the OIG estimates that Aetna received at least $25.5 million in overpayments...
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