Audit says Highmark overbilled federal government $6.2M for Medicare Advantage

PITTSBURGH — The Center for Medicare and Medicaid Services’ Office of Inspector General is recommending Highmark Health’s Medicare Advantage program repay $6.2 million in what it said an audit found were overpayments in the Medicare Advantage program in 2015 and 2016. Highmark is disputing the findings.

The inspector general’s office did an audit of Highmark Senior Health Co., a subsidiary of Pittsburgh-based Highmark Health for 226 medical conditions and high-risk diagnosis codes. In a news release, the inspector said that some diagnosis codes didn’t comply with Medicare Advantage regulations and medical records didn’t match with the diagnosis codes in samples.

“The 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 report said. “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.”

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