Series: Nationwide Audits of Medicare Part C High-Risk Diagnosis Codes

OBJECTIVE

Payments to Medicare Advantage (MA) organizations are risk-adjusted on the basis of the health status of each enrollee. MA organizations are required to submit risk-adjustment data to CMS according to CMS instructions (42 CFR § 422.310(b)). Miscoded diagnoses may cause CMS to pay MA organizations improper amounts (The Act §§ 1853(a)). For these audits, we will focus on enrollees who received diagnoses that are at high risk for being miscoded 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.

There are 2 projects in this series.

Project titles will remain unpublished until projects are complete and reports are posted.

ACTIVE PROJECTS IN THIS SERIES (2)

TIMELINE

• July 17, 2023
  Series Number SRS-A-25-021 Assigned
• July 17, 2023
  Project Announced

  Project A-02-23-01020

• October 7, 2025
  Project Announced

  Project OAS-25-04-152

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

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