What OIG allegedly found:
With respect to the six high-risk groups covered by our audit, most of the selected diagnosis codes that Highmark submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 66 of the 226 sampled enrollee-years, either the medical records validated the reviewed HCCs, or we identified another diagnosis code (on CMS’s systems) that mapped to the HCC under review. However, for the remaining 160 enrollee-years, the diagnosis codes were not supported in the medical records. These errors occurred because the policies and procedures that Highmark had to prevent, detect, and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, could be improved. As a result, the HCCs for these high-risk diagnosis codes were not validated. On the basis of our sample results, we estimated that Highmark received at least $6.2 million of net overpayments for 2015 and 2016.1
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