This overview is excerpted from Manat on Health, Manat’s subscription service that provides deep insights and analysis focused on law, policy, and market trends. For more information on how to subscribe to Manatt on Health and activate your one-week free trial, please contact Barret Jefferds.
On October 24, the HHS Office of Inspector General (OIG) released a report titled “Medicare Benefits: Questionable Use of Health Risk Assessments Continues to Increase Payments to Billions of Plans.” In evaluating 2022 MA encounter data, the OIG found that diagnoses reported based solely on the MA enrollee’s health risk assessment (HRA) and HRA-related chart review, even in the absence of additional benefits. We found that MA risk-adjusted payments in 2023 are estimated to be $7.5 billion. Service records (follow-up visits, procedures, tests, supplies) for diagnoses related to these registrants. The OIG states that “(1) the diagnosis (based on the HRA) is inaccurate and therefore payment is inappropriate, or (2) the enrollee has a severe It was concluded that patients are either not receiving the necessary treatment for their symptoms.
In this report, the OIG made three recommendations to the Centers for Medicare and Medicaid Services (CMS). Specifically, the CMS must:
1. Imposing additional restrictions on diagnoses reported only in home HRAs and the use of medical record reviews associated with home HRAs for risk-adjusted payments.
2. Conduct an audit to verify diagnoses reported only in the home HRA and medical record review related to the HRA.
3. Determine whether the specific health conditions that gave rise to payments from home HRAs and HRA-related medical record reviews may be susceptible to abuse among Medicare Advantage Organizations (MAOs).
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