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Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Highmark Senior Health Company (H3916) Submitted to CMS

Submitting OIG: 
Department of Health & Human Services OIG
Date Issued: 
Thursday, September 29, 2022
Agency Reviewed / Investigated: 
Department of Health & Human Services
Submitting OIG-Specific Report Number: 
A-03-19-00001
Component, if applicable: 
Centers for Medicare & Medicaid Services
Centers for Medicare and Medicaid Services
External entity, if applicable: 
Highmark Senior Health Company
Location(s): 
PA,
United States
Type of Report: 
Audit
Questioned Costs: 
$6,227,005
Funds for Better Use: 
$0
Number of Recommendations: 
3
View Document: 
AttachmentSize
PDF icon 31900001.pdf10.88 MB

Related Open Recommendations

Recommendation Number Recommendation Status Significant Recommendation Additional Details
22-A-03-113.01 Open No
We recommend that Highmark Senior Health Company refund to the Federal Government the $6,227,005 of estimated net overpayments;
22-A-03-113.02 Open No
We recommend that Highmark identify, for the high-risk diagnoses included in the report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government.
22-A-03-113.03 Open No
We recommend that Highmark continue its examination of its existing compliance procedures to identify areas where improvements can be made to ensure 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.
Displaying 3 of 3 Recommendations