Physicians haven't properly coded for stroke patients who transferred from traditional Medicare to Medicare Advantage, leading to inflated payments to Medicare Advantage organizations, according to a Sept. 16 report from HHS' Office of Inspector General.
Select diagnosis codes for acute stroke that map to the ischemic or unspecified stroke hierarchical condition categories are at high risk of being miscoded, according to the OIG. For its audit, OIG reviewed claims for 582 transferred enrollees who received a high-risk acute stroke diagnosis code in 2014 or 2015 to see if medical records support the submitted codes.
OIG found nearly all of the selected acute stroke diagnosis codes that physicians submitted to CMS under traditional Medicare that CMS later used to make payments to Medicare Advantage organizations didn't comply with federal requirements. This resulted in overpayments of $14.4 million to the Medicare Advantage organizations.
"These errors originated from physicians submitting incorrect acute stroke diagnosis codes on claims billed under traditional Medicare. However, these errors were unnoticed and caused inaccurate payments in MA because CMS did not have policies and procedures to identify beneficiaries who transferred from traditional Medicare to MA, and evaluate whether the acute stroke diagnosis codes submitted under traditional Medicare on their behalf complied with federal requirements," the OIG said.
OIG called on CMS to improve its education for physicians and create policies that identify when patients are moving from traditional to Medicare Advantage plans. While CMS said the OIG's findings account for less than a half percent of all transferees, the agency agreed with the recommendations and plans to review and implement new policies.