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Nationwide Audits of Medicare Part C High-Risk Diagnosis Codes

Payments to Medicare Advantage (MA) organizations are risk-adjusted on the basis of the health status of each enrollee. MA organizations are required to submit risk-adjustment data to CMS according to CMS instructions (42 CFR § 422.310(b)). Miscoded diagnoses may cause CMS to pay MA organizations improper amounts (The Act §§ 1853(a)). For these audits, we will focus on enrollees who received diagnoses that are at high risk for being miscoded and resulted in increased risk-adjusted payments from CMS to MA organizations. We will determine whether these diagnosis codes, as submitted by MA organizations to CMS for use in CMS's risk-adjustment program, complied with Federal requirements.

Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY)
June 2023 Centers for Medicare and Medicaid Services Nationwide Audits of Medicare Part C High-Risk Diagnosis Codes Office of Audit Services WA-23-0019 (W-00-23-35896) 2024