On October 21, 2024, the HHS Office of Inspector General (“OIG”) released a report that found CMS paid Medicare Advantage (“MA”) companies approximately $7.5 billion in risk-adjusted payments in 2023 based on diagnosis codes reported only in health risk assessments (“HRAs”), including chart reviews and in-home HRA visits. The report specifically noted that “[t]he lack of any other followup visits, procedures, tests, or supplies for these diagnoses in the MA encounter data for 1.7 million MA enrollees raises concerns that either: (1) the diagnoses 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.” OIG found that just 20 MA companies drove 80% of the estimated $7.5 billion in payments, suggesting that this issue may be concentrated among a relatively small number of MA companies.
To ensure that HRAs and chart reviews are not misused by MA companies, OIG recommends that CMS: “(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, and (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 MA companies.”