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Report File
Date Issued
Submitting OIG
Department of Health & Human Services OIG
Other Participating OIGs
Department of Health & Human Services OIG
Agencies Reviewed/Investigated
Department of Health & Human Services
Components
Centers for Medicare and Medicaid Services
Report Number
A-01-18-00504
Report Type
Audit
Number of Recommendations
3
Questioned Costs
$632,070
Funds for Better Use
$0
External Entity
Aetna, Inc.

Open Recommendations

This report has 4 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
24-A-01-001.01 No $632,070 $0

We recommend that Aetna, Inc. refund to the Federal Government the $632,070 of overpayments.

24-A-01-001.02 No $0 $0

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 No $0 $0

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 No $0 $0

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.

Department of Health & Human Services OIG

United States