Review of CMS Systems Used to Pay Medicare Advantage Organizations

Medicare Advantage (MA) organizations submit to CMS diagnoses on their beneficiaries; in turn, CMS categorizes certain diagnoses into groups of clinically related diseases called hierarchical condition categories (HCC). For instances in which a diagnosis maps to a HCC, CMS increases the risk-adjusted payment. CMS has designed its Medicare Part C systems to capture the necessary data in order to make these increased payments to MA organizations. As CMS transitions to a new data system to make these payments, OIG will conduct analysis to inform both use of current systems and the transition to a new system. We will review the continuity of data maintained on current Medicare Part C systems. Specifically, we will review instances in which CMS made an increased payment to an MA organization for a HCC and determine whether CMS's systems properly contained a requisite diagnosis code that mapped to that HCC.

Announced or Revised	Agency	Title	Component	Report Number(s)	Expected Issue Date (FY)
December 2017	Centers for Medicare & Medicaid Services	Review of CMS Systems Used to Pay Medicare Advantage Organizations	Office of Audit Services	W-00-18-35804	2021