Health Information Management

News: OIG finds PacifiCare received more than $100 million in overpayments

CDI Strategies, August 2, 2012

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A recent Office of the Inspector General report found PacifiCare of Texas received $115 million in CMS overpayments. The OIG reviewed 100 sample cases and found 43 claims with incorrect payments. According to the report, PacifiCare, which administers healthcare plans for approximately 118,000 beneficiaries, submitted diagnosis codes which were not supported by physician documentation.

The 68-page report discussed cases taken from calendar year 2007. In it the OIG described cases where documentation reflected an entirely different diagnosis from that coded and billed to Medicare Advantage. In one example, a diagnosis of peripheral vascular disease was submitted when documentation illustrated that a can fell on the patient’s foot.
 
PacifiCare disagreed with the report findings, claiming its analysis was flawed.



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