CMS May Make Increased Payments to MA Organizations for Diagnoses That Were Reported on Physicians' Claims But Were Not Confirmed on a Concurrent Inpatient Stay

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.

Announced or Revised	Agency	Title	Component	Report Number(s)	Expected Issue Date (FY)
July 2023	Centers for Medicare and Medicaid Services	CMS May Make Increased Payments to MA Organizations for Diagnoses That Were Reported on Physicians' Claims But Were Not Confirmed on a Concurrent Inpatient Stay	Office of Audit Services	WA-23-0032 (W-00-23-35900)	2025