Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Triple-S Advantage, Inc., (Contract H5774) Submitted to CMS

Date Issued

Thursday, December 19, 2024

Submitting OIG

Department of Health & Human Services OIG

Agencies Reviewed/Investigated

Department of Health & Human Services

Report Number

A-04-21-07095

Report Type

Audit

Agency Wide

Yes

Number of Recommendations

Questioned Costs

$296,758

Funds for Better Use

Report updated under NDAA 5274

External Link

Open Recommendations

This report has 3 open recommendations.

Recommendation Number	Significant Recommendation	Recommended Questioned Costs	Recommended Funds for Better Use
25-A-04-030.01	No	$296,758	$0
We recommend that Triple-S Advantage, Inc. refund to the Federal Government $296,758 in net overpayments.
25-A-04-030.02	No	$0	$0
We recommend that Triple-S Advantage, 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.
25-A-04-030.03	No	$0	$0
We recommend that Triple-S Advantage, 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 of 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.