Are You Prepared to Avoid Repayments

September 8th, 2022 - Raquel Shumway
Categories:   Practice Management  

The Office of the Inspector General (OIG), after completing an audit on a Medicare Advantage Plan in August 2022, is now demanding repayment of claims to the tune of $3,518,465. Although the payer is contesting that amount, it is possible that they may begin demanding repayments from the providers to cover their costs of repayment. Therefore, it goes without saying that providers should pay attention to what the OIG is saying in order to properly code and document claims so as to not get caught in the repayment game. Do an internal audit, to make sure you are meeting individual payer requirements.

This particular report covered 7 high risk groups:

  1. Acute Stroke

  2. Acute Heart Attack

  3. Acute Stroke and Acute Heart Attack Combination

  4. Embolism

  5. Major Depressive Disorder

  6. Vascular Claudication

  7. Potentially Mis-keyed Diagnosis Codes

Issues identified by the OIG are:

  • Submitting an incorrect diagnosis codes

    • Incorrect or old diagnosis codes were used

  • Mis-keying a diagnosis code

    • For example transposing a number (250.00 diabetes mellitus instead of 205.00 acute myeloid leukemia)

  • Policies and procedures used “ were not always effective”

  • Documentation not found to support the diagnosis

    • No documentation found and/or submitted to provide support of the diagnosis

    • Insufficient documentation to validate the code used

Policies and Procedures

It is always important to make sure that there are policies and procedures in place to help avoid miscoding, poor documentation, and consequently repayments. It might be helpful to take the time to do your own internal audit of your policies and procedures and make sure that they are keeping you on track to avoiding problems. The OIG stated: 

“These errors we identified occurred because the policies and procedures that WellCare had to prevent, detect, and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations (42 CFR § 422.503(b)(4)(vi)), were not always effective.”


In a few instances, the Medicare Advantage organization (MAO) was able to show that the OIG misread the documentation. Documentation that makes it easy to see what the diagnosis is and why that diagnosis becomes important so as not to have to spend time later proving that your code selection and documentation are correct.

Documentation issues you might want to consider:

  • Does it accurately state what the current visit is for in a clear, easy to find statement?

  • Does the code used clearly reflect the reason for the current visit?

  • Is the documentation accurate?

  • Do not carry forward information from a previous visit unless it is applicable (e.g., managed or considered) to the current encounter?
    For example: Current medications — Is it an old list from a previous visit? Or does it reflect those currently  being taken by the patient?

  • Avoid over documentation and/or unnecessary or irrelevant information.
    Don’t cloud the important information with what is not necessary, it can waste time and leads to miscommunication.

  • Are there procedures set up to protect your organization from miscoding the diagnosis?


The conclusion is that watchful care when entering the codes on a claim, having proper policies in place to help correct something before it becomes an issue, and proper, clear documentation is key to avoiding problems down the road. Make it easy for auditors to follow and to locate the support for any diagnosis.

To view the entire OIG report Click Here.


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