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On October 24, the HHS Office of Inspector General (OIG) released a report titled “Medicare Advantage: Questionable Use of Health Risk Assessments Continues to Drive Up Payments to Plans by Billions.” In evaluating 2022 MA encounter data, OIG found that diagnoses reported based only on MA enrollees’ health risk assessments (HRAs) and HRA-linked chart reviews resulted in an estimated $7.5 billion in MA risk-adjusted payments for 2023 even when there were no additional service records—follow-up visits, procedures, tests, or supplies—for the diagnoses associated with these enrollees. OIG concludes that “either: (1) the diagnoses [based on HRAs] are inaccurate and thus the payments are improper or (2) enrollees did not receive needed care for serious conditions reported only on HRAs or HRA-linked chart reviews.”
In this report, the OIG made three recommendations to the Centers for Medicare & Medicaid Services (CMS). Specifically, CMS should:
1. Impose additional restrictions on the use of diagnoses reported only on in-home HRAs or chart reviews that are linked to in-home HRAs for risk-adjusted payments.
2. Conduct audits to validate diagnoses reported only on in-home HRAs and HRA-linked chart reviews.
3. Determine whether select health conditions that drove payments from in-home HRAs and HRA-linked chart reviews may be more susceptible to misuse among Medicare Advantage Organizations (MAOs).
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