Latest OIG Risk Adjustment Audit Seeks $6.4 Million From UPMC

  • Dec 02, 2021

    Continuing a series of audits in which the HHS Office of Inspector General is reviewing the accuracy of diagnosis codes submitted to CMS by Medicare Advantage organizations, OIG last month said most of the codes it reviewed for UPMC Health Plan, Inc. could not be validated by medical records. The agency used its own extrapolation methodology to estimate that the Pittsburgh-based insurer owes $6.4 million for the 2015 and 2016 payment years, prompting a detailed rebuttal from UPMC and adding to the ongoing debate over the use of sampling to approximate a plan’s true payment error rate. Read more
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  • Lauren Flynn Kelly

    Lauren has been covering health business issues since the early 2000s and specializes in in-depth reporting on Medicare Advantage, managed Medicaid and Medicare Part D. She also possesses a deep understanding of the complex world of pharmacy benefit management, having written AIS Health’s Radar on Drug Benefits from 2004 to 2005 and again from 2011 to 2016. In addition to her role as managing editor of Radar on Medicare Advantage, she oversees AIS Health’s publications and manages the health editorial staff. She graduated from Vassar College with a B.A. in English.

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