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Medicare Advantage Risk-Adjustment Data - Targeted Review of Documentation Supporting Specific Diagnosis Codes

Payments to Medicare Advantage (MA) organizations are risk-adjusted on the basis of the health status of each beneficiary. MA organizations are required to submit risk-adjustment data to CMS in accordance with CMS instructions (42 CFR § 422.310(b)), and inaccurate diagnoses may cause CMS to pay MA organizations improper amounts (SSA §§ 1853(a)(1)(C) and (a)(3)). In general, MA organizations receive higher payments for sicker patients. CMS estimates that 9.5 percent of payments to MA organizations are improper, mainly due to unsupported diagnoses submitted by MA organizations. Prior OIG reviews have shown that some diagnoses are more at risk than others to be unsupported by medical record documentation. We will perform a targeted review of these diagnoses and will review the medical record documentation to ensure that it supports the diagnoses that MA organizations submitted to CMS for use in CMS's risk score calculations and determine whether the diagnoses submitted complied with Federal requirements.

Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY)
Completed (partial) Centers for Medicare & Medicaid Services Medicare Advantage Risk-Adjustment Data - Targeted Review of Documentation Supporting Specific Diagnosis Codes Office of Audit Services A-07-19-01187;
A-07-19-01188;
A-07-17-01173;
W-00-20-35079;
W-00-18-35079;
W-00-19-35079;
W-00-17-35079;
W-00-21-35079;
W-00-24-35079;
A-01-19-00500;
A-02-18-01029;
A-06-18-05002;
A-03-18-00002;
A-04-19-07084;
A-03-19-00001;
A-05-19-00039;
A-07-19-01195;
A-02-20-01009;
A-09-20-03009;
A-07-19-01193;
A-01-20-00500;
A-09-19-03001;
A-09-21-03011;
A-07-19-01192;
A-02-20-01008;
A-05-19-00013;
A-03-20-00001;
A-07-20-01197;
A-07-20-01202;
A-06-19-05002;
A-01-18-00504;
A-07-20-01198;
A-05-22-00020;
A-02-22-01001;
various reviews		 2025