Series: Medicare Part C Audits of Documentation Supporting Specific Diagnosis Codes

OBJECTIVE

Payments to Medicare Advantage (MA) organizations are risk-adjusted based on 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. In general, MA organizations receive higher payments for enrollees with more complex diagnoses. CMS estimates that 9.5 percent of payments to MA organizations are improper, mainly due to unsupported diagnoses submitted by MA organizations. Prior OIG reviews have shown that some diagnoses are more at risk than others to be unsupported by medical record documentation. We will perform a targeted review of these diagnoses and will review the medical record documentation to ensure that it supports the diagnoses that MA organizations submitted to CMS for use in CMS's risk score calculations and to determine whether the diagnoses submitted complied with Federal requirements.

There are 5 projects in this series.

Project titles will remain unpublished until projects are complete and reports are posted.

ACTIVE PROJECTS IN THIS SERIES (5)

TIMELINE

• October 3, 2023
  Series Number SRS-A-25-017 Assigned
• October 3, 2023
  Projects Announced

  Project A-07-24-01214

• Project A-07-24-01215

• January 29, 2024
  Project Announced

  Project A-06-24-05002

• January 30, 2024
  Project Announced

  Project A-05-24-00010

• September 11, 2024
  Project Announced

  Project A-02-24-01019

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

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