HHS-OIG Says Highmark Senior Health Upcoded $6.2M

The payer disputes an audit finding that 70% of the diagnosis codes submitted for 'high risk groups' in 2016 and 2016 'did not comply with Federal requirements.'

Highmark Senior Health Company overcharged the federal government by an estimated $6.2 million in 2015-16, federal watchdogs say, and they want a refund.

The Department of Health and Human Services Office of the Inspector General, in an audit made public Monday, examined "six high-risk groups" billed by Highmark's Medicare Advantage plan in 2015-16 and found that 160 out of 226 randomly selected diagnosis codes with charges totaling $801,166 "were not supported in the medical records." Based on that sample, OIG estimates that "Highmark received at least $6.2 million of net overpayments for 2015 and 2016."

The six high-risk diagnosis codes are: acute stroke; acute heart attack; embolism; vascular claudication' major depressive disorder; and potentially mis-keyed diagnosis codes.

"With respect to the six high-risk groups covered by our audit, most of the selected diagnosis codes that Highmark submitted to the Centers for Medicare & Medicaid Services for use in CMS's risk adjustment program did not comply with Federal requirements," the audit says.

"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," the audit says. "As a result, the Hierarchical Condition Categories (diagnosis code groupings based on similarity of clinical characteristics, severity, and cost implications) for these high-risk diagnosis codes were not validated."

The audit recommends that Highmark refund the $6.2 million, identify similar instances of noncompliance for high-risk diagnoses before and after the audit period and refund any overpayments they find, and review existing compliance procedures to identify areas where improvements can be made. 

Highmark Rebuttal

Highmark issued a statement saying it "disagreed with OIG's findings on a number of grounds and requested that it withdraw its recommendation."

"Additionally, Highmark's review and analysis demonstrated that the audit only targeted records that supported an over payment, and that if the audit targeted records that supported underpayments as well the results would have been materially different," the statement said.