Series: Risk Adjustment Data - Sufficiency of Documentation Supporting Diagnoses

OBJECTIVE

Payments to Medicare Advantage organizations are risk adjusted on the basis of the health status of each beneficiary. Medicare Advantage organizations are required to submit risk adjustment data to Centers for Medicare & Medicaid Services in accordance with Centers for Medicare & Medicaid Services instructions (42 CFR § 422.310(b)), and inaccurate diagnoses may cause Centers for Medicare & Medicaid Services to pay Medicare Advantage organizations improper amounts (SSA §§ 1853(a)(1)(C) and (a)(3)). In general, Medicare Advantage organizations receive higher payments for sicker patients. Centers for Medicare & Medicaid Services estimates that 9.5 percent of payments to Medicare Advantage organizations are improper, mainly due to unsupported diagnoses submitted by Medicare Advantage organizations. Prior OIG reviews have shown that medical record documentation does not always support the diagnoses submitted to Centers for Medicare & Medicaid Services by Medicare Advantage organizations. We will review the medical record documentation to ensure that it supports the diagnoses that Medicare Advantage organizations submitted to Centers for Medicare & Medicaid Services for use in Centers for Medicare & Medicaid Services' risk score calculations and determine whether the diagnoses submitted complied with Federal requirements.

There are 3 projects in this series.

COMPLETED PROJECTS IN THIS SERIES (3)

Medicare Advantage Compliance Audit of Diagnosis Codes That EmblemHealth (Contract H3330) Submitted to CMS

Project A-06-18-02001 • Completed on September 24, 2024

Medicare Advantage Compliance Audit of Diagnosis Codes That MMM Healthcare, LLC, (Contract H4003) Submitted to CMS

Project A-04-20-07090 • Completed on August 13, 2024

Medicare Advantage Compliance Audit of Diagnosis Codes That Humana, Inc. (Contract H1036), Submitted to CMS

Project A-07-16-01165 • Completed on April 19, 2021

TIMELINE

• July 15, 2016
  Series Number W-00-24-35078 Assigned
• July 15, 2016
  Project Announced

  Medicare Advantage Compliance Audit of Diagnosis Codes That Humana, Inc. (Contract H1036), Submitted to CMS - A-07-16-01165

• March 12, 2018
  Project Announced

  Medicare Advantage Compliance Audit of Diagnosis Codes That EmblemHealth (Contract H3330) Submitted to CMS - A-06-18-02001

• December 12, 2019
  Project Announced

  Medicare Advantage Compliance Audit of Diagnosis Codes That MMM Healthcare, LLC, (Contract H4003) Submitted to CMS - A-04-20-07090

• April 19, 2021
  Project Complete - A-07-16-01165

  Medicare Advantage Compliance Audit of Diagnosis Codes That Humana, Inc. (Contract H1036), Submitted to CMS has been marked as complete. This audit resulted in 2 recommendations.

• August 13, 2024
  Project Complete - A-04-20-07090

  Medicare Advantage Compliance Audit of Diagnosis Codes That MMM Healthcare, LLC, (Contract H4003) Submitted to CMS has been marked as complete. This audit resulted in 2 recommendations.

• September 24, 2024
  Project Complete - A-06-18-02001

  Medicare Advantage Compliance Audit of Diagnosis Codes That EmblemHealth (Contract H3330) Submitted to CMS has been marked as complete. This audit resulted in 2 recommendations.

• September 24, 2024
  Series Complete

  Risk Adjustment Data - Sufficiency of Documentation Supporting Diagnoses has been marked as complete.

3 REPORT PUBLISHED

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