OBJECTIVE
Payments to Medicare Advantage (MA) organizations are risk adjusted on the basis of each enrollee's health status (SSA § 1853(a)). One tool that MA organizations use to collect risk adjusted data is the health risk assessment (HRA), which gathers information about enrollees, including health status and health risks. 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. For these audits, the focus is on enrollees whose diagnoses, reported only on HRAs, mapped to HCCs 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.
There are 5 projects in this series.
Project titles will remain unpublished until projects are complete and reports are posted.
ACTIVE PROJECTS IN THIS SERIES (5)
TIMELINE
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February 14, 2023Series Number SRS-A-25-020 Assigned
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September 20, 2023Project Announced
Project A-07-23-01212
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April 18, 2025Project Announced
Project OAS-25-05-093
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May 29, 2025Project Announced
Project OAS-25-04-103
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July 1, 2025Project Announced
Project OAS-25-09-129
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July 10, 2025Project Announced
Project OAS-25-09-130
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Today5 Projects In-Progress
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Est FY2026Estimated Fiscal Year for Series Completion