BC Advantage - 2021 Issue 5
Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Anthem Community Insurance Company, Inc. (Contract H3655) Submitted to CMS
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Article Overview
This article summarizes an Office of Inspector General audit of Anthem Community Insurance Company’s Medicare Advantage risk adjustment submissions to CMS. It explains the audit purpose, sampling approach, identified noncompliance, estimated overpayments, and the recommendations and response from Anthem. The report is relevant to compliance, audit, risk adjustment, and Medicare Advantage billing oversight.
Why This Topic Matters
The report addresses how diagnosis-code documentation and submission issues can affect Medicare Advantage payment accuracy and create overpayment risk. It is useful for compliance teams, auditors, and risk adjustment stakeholders monitoring MA documentation and program integrity.
What You Will Learn
- Why OIG selected this Medicare Advantage organization for review
- How the audit sample was constructed and what payment amounts were examined
- What the audit found regarding compliance and overpayment risk
- What recommendations OIG made and how Anthem responded
Who Should Read This
- Compliance officers
- Medical auditors
- Risk adjustment professionals
- Medicare Advantage plan administrators
- Healthcare reimbursement teams
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