OIG audit: Aetna may have raked in $25.5M in MA overpayments in 2015, 2016

A new federal audit estimates that Aetna may have received at least $25.5 million in overpayments from Medicare Advantage in 2015 and 2016.

The Department of Health and Human Services Office of Inspector General (OIG) sampled 210 unique enrollee years, weighing whether submitted diagnostic codes complied with federal requirements. For 155 of the years studied, the records submitted by Aetna did not match with the diagnoses, according to the analysis (PDF).

That led to $632,070 in overpayments, which extrapolates out to $25.5 million overall, OIG said.

"As demonstrated by the errors found in our sample, Aetna’s policies and procedures to prevent, detect, and correct noncompliance with [the Centers for Medicare & Medicaid Services' (CMS')] program requirements, as mandated by Federal regulations, could be improved," OIG said.

A lengthy rebuttal from Aetna is attached to the report, where the insurer says it finds "numerous flaws" in the methodology for the audit. It also said it takes issue with how OIG conducted medical record reviews.

In a statement to Fierce Healthcare, the company and its parent, CVS Health, said they "respectfully disagree" with the findings.

"We note that, while OIG identified an overpayment amount across our entire contract, that recommendation is not consistent with CMS regulations and is not applicable to the audit at issue," Aetna said. "However, we are pleased that OIG recognized the efforts we put into our compliance program."

"Aetna is committed to providing Medicare Advantage members with greater value and better outcomes on their health journeys and we strive to maintain a candid and collaborative approach with OIG," the company added.

In the OIG report, the agency noted that Aetna "disagreed with our audit methodology, medical record review process and use of extrapolation." OIG said Aetna also did not agree with the agency's finding for five of the sampled enrollee years and did not specify agreement or disagreement with the remaining years. It also did not concur with the agency's recommendations on the matter.

OIG recommended that Aetna repay the federal government for the potential $632,070 in overpayments that were identified in the report. The insurer should also continue to review and enhance its compliance policies, OIG said.

The agency also said that updated regulations from the CMS led it to request repayment solely for overpayments identified in the sample as CMS said payments could only be recouped beginning with the 2018 plan year.