Audit of Diagnoses that Humana, Inc. Submitted to CMS For Use in CMS's Medicare Part C Risk Adjustment Program

OBJECTIVE

Payments to Medicare Advantage organizations (MAOs) are risk-adjusted based on the health status of each enrollee (Social Security Act §§ 1853(a)). MAOs are required to submit risk-adjustment data to CMS according to CMS instructions (42 CFR § 422.310(b)). Inaccurate diagnoses may cause CMS to pay improper amounts to MAOs. For this audit, we will focus on diagnoses that are at high risk for not being supported by medical records for a face-to-face encounter with an acceptable provider type and resulted in increased risk-adjusted payments from CMS to MAOs. We will determine whether MAOs’ submission of these diagnosis codes to CMS, for use in CMS’s risk-adjustment program, complied with Federal requirements.

TIMELINE