Series: Medicare Advantage Health Risk Assessments – Continuity of Care

OBJECTIVE

CMS makes monthly risk-adjusted payments to Medicare Advantage (MA) organizations based in part on the health characteristics of the enrollees being covered (Social Security Act § 1853(a)). Federal regulations at 42 CFR § 422.310(b) require that MA organizations submit risk adjustment data, which includes diagnosis codes, to CMS in accordance with CMS instructions. Inaccurate diagnoses may cause CMS to pay MA organizations improper amounts. MA organizations use health risk assessments (HRAs) to gather information, including diagnoses, about enrollees. MA organizations can use HRAs for early identification of health risks to improve enrollees’ care and health outcomes. However, prior OIG work found that MA organizations may have inappropriately leveraged HRAs to maximize risk-adjusted payments. These audits focused on enrollees whose diagnoses, reported first on HRAs, mapped to hierarchical condition categories and resulted in increased risk-adjusted payments from CMS to MA organizations. We will determine whether MA organizations complied with Federal requirements when: (1) submitting diagnoses reported on HRAs to CMS for use in CMS’s risk-adjustment program and (2) taking any needed steps to ensure continuity of care and integration of services for enrollees who had received HRAs.

There are 3 projects in this series.

Project titles will remain unpublished until projects are complete and reports are posted.

ACTIVE PROJECTS IN THIS SERIES (3)

TIMELINE

• November 15, 2024
  Series Number SRS-A-25-019 Assigned
• November 15, 2024
  Projects Announced

  Project OAS-24-07-015

• Project OAS-25-07-125

• Project OAS-25-07-126

• Today
  3 Audits In-Progress
• Est FY2026
  Estimated Fiscal Year for Series Completion

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