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Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Presbyterian Health Plan, Inc. (Contract H3204) Submitted to CMS

Submitting OIG:

Department of Health & Human Services OIG

Date Issued:

Thursday, August 3, 2023

Agency Reviewed / Investigated:

Department of Health & Human Services

Submitting OIG-Specific Report Number:

A-07-20-01197

Component, if applicable:

Centers for Medicare & Medicaid Services

Centers for Medicare and Medicaid Services

External entity, if applicable:

Presbyterian Health Plan, Inc.

Location(s):

NM,

United States

Type of Report:

Audit

Questioned Costs:

$1,302,682

Funds for Better Use:

$0

Number of Recommendations:

3

Report updated under NDAA 5274:

No

View Document:

Attachment	Size
72001197.pdf	1.69 MB

Related Open Recommendations

Recommendation Number	Recommendation Status	Significant Recommendation	Additional Details
23-A-07-099.01	Open	No
We recommend that Presbyterian Health Plan, Inc., refund to the Federal Government the $1,302,682 of estimated net overpayments.
23-A-07-099.02	Open	No
We recommend that Presbyterian Health Plan, 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.
23-A-07-099.03	Open	No
We recommend that Presbyterian Health Plan, Inc., continue its examination of 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.