Under the Medicare Advantage (MA) program, the Centers for Medicare & Medicaid Services (CMS) makes predetermined monthly payments to MA organizations according to a system of risk adjustment that depends on the health status of each enrollee. Accordingly, MA organizations are paid more for providing benefits to sicker enrollees than to healthier enrollees. To determine the health status of enrollees, CMS relies on MA organizations to collect diagnosis codes from their providers and submit these codes to CMS. Some diagnoses are at higher risk for being miscoded, which may result in overpayments from CMS.
Tuesday, April 30, 2019
Agency Reviewed / Investigated:
Submitting OIG-Specific Report Number:
Component, if applicable:
Centers for Medicare & Medicaid Services
External entity, if applicable:
Essence Healthcare, Inc.
Maryland Heights, MOUnited States
Type of Report:
Number of Recommendations: