OBJECTIVE
Payments to Medicare Advantage (MA) organizations are risk adjusted on the basis of each enrollee's health status (SSA § 1853(a)). 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 this review, we will focus on enrollees who had a diagnosis on a physician or outpatient claim that did not appear on a concurrent inpatient claim. In these instances, the diagnosis codes from the physician or outpatient claim-ostensibly, potentially unconfirmed diagnosis codes that misrepresented the health status of the enrollee-were submitted to CMS and resulted in increased payments to MA organizations. If these occurrences were reviewed as part of a Risk Adjustment Data Validation (RADV) audit (or during a subsequent RADV appeals process), CMS could potentially review the claims collectively, instead of separately, in order to ensure the accuracy of the enrollee's health status. We will identify the increased payments to MA organizations that were based on any unconfirmed and inaccurate diagnoses.
There are 7 projects in this series.
ACTIVE PROJECTS IN THIS SERIES (6)
CANCELED PROJECTS IN THIS SERIES (1)
Medicare Advantage Compliance Audit of Specific Diagnosis Codes Reported Only on Health Risk Assessments That Independent Health Association, Inc. (Contract H3362), Submitted to CMS
TIMELINE
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February 14, 2023Series Number SRS-A-25-020 Assigned
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February 14, 2023Project Announced
Project A-07-23-01210
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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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April 24, 2025Project Announced
Medicare Advantage Compliance Audit of Specific Diagnosis Codes Reported Only on Health Risk Assessments That Independent Health Association, Inc. (Contract H3362), Submitted to CMS - OAS-25-04-096
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April 24, 2025Project Canceled - OAS-25-04-096
Medicare Advantage Compliance Audit of Specific Diagnosis Codes Reported Only on Health Risk Assessments That Independent Health Association, Inc. (Contract H3362), Submitted to CMS
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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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Today6 Audits In-Progress
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Est FY2026Estimated Fiscal Year for Series Completion