Medicare Advantage Compliance Audit of Diagnosis Codes

This technical report presents the findings of an audit conducted by the Office of Inspector General (OIG) regarding the compliance of MMM Healthcare, LLC with Federal requirements for diagnosis codes submitted to the Centers for Medicare & Medicaid Services (CMS). The audit aimed to determine whether MMM submitted diagnosis codes accurately for the risk adjustment program. A sample of 200 enrollees was reviewed, revealing that while 580 of the 688 submitted Hierarchical Condition Categories (HCCs) were validated, 108 were not. This discrepancy resulted in net overpayments amounting to $165,312, with an estimated total of approximately $59 million in overpayments for the year 2017. The report recommends that MMM refund the overpayments and enhance its compliance procedures. MMM disagreed with some findings and recommendations, asserting that the audit's conclusions did not align with CMS and HHS standards. The report concludes with a summary of the audit methodology and findings, alongside MMM's comments and OIG's responses.