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Audits of Medicare Part C Health Risk Assessment Diagnosis Codes

Payments to Medicare Advantage (MA) organizations are risk-adjusted based on 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 a hierarchical condition category 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)
November 2023 Centers for Medicare and Medicaid Services Audits of Medicare Part C Health Risk Assessment Diagnosis Codes Office of Audit Services WA-24-0003 (W-00-24-35905) 2025