CMS overpaid Excellus $41M for Medicare Advantage plans

Excellus Blue Cross Blue Shield was overpaid $41.6 million to administer Medicare Advantage health plans, according to an audit from the Office of Inspector General.

The audit reviewed a sampling of 98 people out of the total 48,000 enrolled in Excellus Medicare Advantage plans--for which the New York insurer was paid $488 million--and found Excellus failed to properly document patient diagnoses. Excellus submitted documentation that didn't support the doctor's diagnosis, failed to provide any documentation or didn't confirm the diagnosis, the Central New York Business Journal reported.

The OIG determined the Centers for Medicare & Medicaid Services overpaid Excellus more than $157,000 for those 98 members and, therefore, estimated Excellus was overpaid a total of $41.6 million for all its Medicare Advantage members in 2007, reported the Syracuse Post-Standard.

However, Excellus disagreed with the OIG's findings, claiming the audit was based on flawed data because Excellus must rely on providers' diagnoses even though they're held liable by CMS for the accuracy of those diagnoses.

"We audit a portion of the claims and medical records for accuracy, completeness, and consistency," Elizabeth Martin, vice president of communications for Excellus, said in a statement within the report. "However, the medical-delivery system would grind to a halt if we made every provider submit all of the documentation for each and every claim they file on behalf of members."

To learn more:
- here's the OIG audit report
- read the Syracuse Post-Standard article
- check out the Central New York Business Journal article