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Financial Impact of Health Risk Assessments and Chart Reviews on Risk Scores in Medicare Advantage

Under Medicare Part C, the Centers for Medicare & Medicaid Services (CMS) makes advanced monthly payments to Medicare Advantage (MA) organizations for each beneficiary enrolled. CMS risk adjusts these payments based on beneficiaries' demographic information and clinical diagnoses from the prior year to pay MA organizations more for beneficiaries with higher expected costs. MA organizations submit to CMS encounter data, which are records of services provided to beneficiaries, including all diagnoses. Currently, CMS includes diagnoses from health risk assessments, which are visits to evaluate a beneficiary's health risks, and chart reviews, which are records based on MA organizations' review of beneficiaries' medical records, when calculating risk scores and risk-adjustment payments. This is allowed regardless of whether these diagnoses are supported by another service rendered to the beneficiary during that year. This study will determine the extent to which diagnoses solely generated by health risk assessments and chart reviews were associated with higher risk scores and higher MA payments. In addition, this study will determine the extent to which diagnoses removed by chart reviews were associated with lower risk scores and lower MA payments.

Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY)
January 2018 Centers for Medicare & Medicaid Services Financial Impact of Health Risk Assessments and Chart Reviews on Risk Scores in Medicare Advantage Office of Evaluation and Inspections OEI-03-17-00470 2019

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