Medicare Advantage Compliance Audit of Specific Diagnosis Codes That UPMC Health Plan, Inc. (Contract H3907) Submitted to CMS

Submitting OIG:

Date Issued:

Friday, November 5, 2021

Agency Reviewed / Investigated:

Submitting OIG-Specific Report Number:

A-07-19-01188

Component, if applicable:

Centers for Medicare & Medicaid Services

Type of Report:

Audit

Questioned Costs:

$6,401,297

Funds for Better Use:

Number of Recommendations:

Related Open Recommendations

Recommendation Number	Recommendation Status	Significant Recommendation
271223	Open	No
Refund to the Federal Government the $6,401,297 of estimated net overpayments.
271224	Open	No
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.
271225	Open	No
Continue its examination of 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.