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Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Aetna, Inc. (Contract H5521) Submitted to CMS

Submitting OIG:

Department of Health & Human Services OIG

Date Issued:

Monday, October 2, 2023

Agency Reviewed / Investigated:

Department of Health & Human Services

Submitting OIG-Specific Report Number:

A-01-18-00504

Component, if applicable:

Centers for Medicare & Medicaid Services

Centers for Medicare and Medicaid Services

External entity, if applicable:

Aetna, Inc.

Location(s):

United States

Type of Report:

Audit

Questioned Costs:

$632,070

Funds for Better Use:

$0

Number of Recommendations:

3

Report updated under NDAA 5274:

No

View Document:

Attachment	Size
11800504.pdf	2.57 MB

Related Open Recommendations

Recommendation Number	Recommendation Status	Significant Recommendation	Additional Details
24-A-01-001.01	Open	No
We recommend that Aetna, Inc. refund to the Federal Government the $632,070 of overpayments.
24-A-01-001.02	Open	No
We recommend that Aetna, Inc. determine, for the remaining 159 enrollee-years in the potentially mis-keyed diagnosis code high-risk group not reviewed as part of this audit, whether the medical records in each case support the diagnosis for the unrelated condition and refund any resulting overpayments to the Federal Government.
24-A-01-001.03	Open	No
We recommend that Aetna, Inc. identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government.
24-A-01-001.04	Open	No
We recommend that Aetna, Inc. continue to examine its existing compliance procedures to identify areas where improvements can be made to ensure that diagnosis codes that are at high risk for being miscoded comply with Federal requirements (when submitted to CMS for use in CMS's risk adjustment program) and take the necessary steps to enhance those procedures.