HHS Inspector General Flags MA Risk Adjustment

Report recommends more CMS oversight and audits
Robert Calandra

A new report from the HHS inspector general’s office examined payments billed by insurers for Medicare Advantage plans and found that the companies obtained billions of dollars in additional payments. 

"Our findings highlight potential issues about the extent to which chart reviews are leveraged by MAOs [Medicare Advantage organizations] and overseen by CMS," said a user-friendly summary of the report posted on the HHS inspector general's website. "Based on our analysis of MA encounter data, we found that MAOs almost always used chart reviews as a tool to add, rather than to delete, diagnoses—over 99 percent of chart reviews in our review added diagnoses."

You can find full text of the report here

The thumbnail says the findings raise "potential concerns" about the completeness of payment data submitted to CMS, the validity of diagnoses, and the quality of care provided to beneficiaries.  The report's recommendations are that the CMS provide oversight of Medicare Advantage plans that had payments resulting from unlinked chart reviews for beneficiaries, that it conduct audits that validate diagnoses reported on chart reviews, and that it reassess the risks and benefits of allowing unlinked chart reviews to be used as sources of diagnoses for risk adjustment.

Medicare Advantage plans are becoming increasingly popular. In 2018, they provided coverage to 21 million people, or about a third of those covered under the Medicare program. Of the $711 billion spent on Medicare last year, $210 billion went to MA plans.