HHS OIG Report Finds that CMS Made Additional Risk-Adjusted Payments Related to Health Risk Assessments

A recent OIG report found that diagnoses reported in 2022 Medicare Advantage (MA) encounter data based only on health risk assessments (HRA) and HRA-linked chart reviews resulted in CMS making additional risk-adjusted payments of about $7.5 billion in 2023 (the Report). Of that $7.5 billion, OIG estimates that $4.8 billion was driven by in-home HRAs and HRA-linked chart reviews. The Report continues OIG’s recent work on risk adjustment encounter data supporting payments to MA organizations, including past reports on estimates of apparently disproportionate MA payments resulting from the use of HRAs (particularly in-home HRAs) and chart reviews.

Background on MA Risk-Adjusted Payments

CMS pays private MA organizations to administer MA plans on a capitated basis to pay for the...

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