OBJECTIVE
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 according to CMS instructions (42 CFR § 422.310(b)). CMS allows MA organizations to conduct chart reviews of enrollee medical record documentation to identify diagnosis codes that providers either: (1) did not originally provide the MA organization or (2) provided the MA organization in error. For some chart reviews known as unlinked chart reviews, CMS does not require that the MA organization identify the specific date of service for previously unidentified diagnosis codes. CMS also allows MA organizations to submit chart review results to CMS for inclusion in calculating each enrollee's risk score. Miscoded diagnoses may cause CMS to pay MA organizations improper amounts. For these audits, we will focus on enrollees who had diagnoses identified from unlinked chart reviews that resulted in increased risk-adjusted payments from CMS to MA organizations. For these enrollees, we will determine whether all of the diagnosis codes that the MA organizations submitted to CMS for use in CMS's risk adjustment program, including the diagnosis codes submitted via unlinked chart reviews, complied with Federal requirements.
There are 5 projects in this series.
ACTIVE PROJECTS IN THIS SERIES (5)
TIMELINE
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August 21, 2023Series Number SRS-A-25-018 Assigned
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August 21, 2023Project Announced
Project A-01-23-00503
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March 13, 2025Project Announced
Project OAS-25-02-054
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May 29, 2025Project Announced
Project OAS-25-04-101
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June 13, 2025Project Announced
Project OAS-25-04-107
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August 27, 2025Project Announced
Project OAS-25-02-144
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Today5 Audits In-Progress
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Est FY2026Estimated Fiscal Year for Series Completion