A recent audit from the HHS Office of Inspector General (OIG) estimates that Blue Cross Blue Shield of Alabama may have received at least $7 million in Medicare Advantage overpayments.
The findings are based on a review of 271 enrollee-years, where the majority showed discrepancies between submitted diagnosis codes and supporting medical records. These inconsistencies led to approximately $769,000 in identified overpayments within the sample, which OIG used to project the larger total. The audit focused on cases from 2017–2018 involving high-risk diagnosis codes.
According to the report, several serious conditions—including lung cancer, sepsis, strokes, and heart attacks—were among the primary contributors to the payment differences. Many of the issues stemmed from diagnoses being reported as active rather than historical, as well as insufficient documentation to support the coding.
Centers for Medicare & Medicaid Services (CMS) paid the insurer roughly $1.8 billion in Medicare Advantage funds during the 2018–2019 payment years, underscoring the scale of the program and the importance of accurate coding.
BCBS Alabama has disputed portions of the audit, noting that some findings reflect documentation and coding gaps at the provider level rather than intentional wrongdoing. The insurer also indicated that repayment amounts have not yet been finalized, as the findings are still under review by CMS.
Resource: BCBS Alabama estimated to have received at least $7M in MA overpayments: OIG – Becker’s Payer Issues