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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 2018

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