Billions in Estimated Medicare Advantage Payments From Diagnoses Reported Only on Health Risk Assessments Raise Concerns

Date Issued

Tuesday, September 8, 2020

Submitting OIG

Department of Health & Human Services OIG

Other Participating OIGs

Department of Health & Human Services OIG

Agencies Reviewed/Investigated

Department of Health & Human Services

Report Number

OEI-03-17-00471

Report Type

Inspection / Evaluation

Agency Wide

Yes

Number of Recommendations

Questioned Costs

Funds for Better Use

Open Recommendations

This report has 5 open recommendations.

Recommendation Number	Significant Recommendation	Recommended Questioned Costs	Recommended Funds for Better Use
6502	No	$0	$0
CMS should require MAOs to implement best practices to ensure care coordination for HRAs.
6503	Yes	$0	$0
CMS should provide targeted oversight of the 10 parent organizations that drove most of the risk-adjusted payments resulting from in-home HRAs.
6504	Yes	$0	$0
CMS should provide targeted oversight of the 20 MAOs that drove risk-adjusted payments resulting from in-home HRAs for beneficiaries who had no other service records in the 2016 encounter data.
6505	No	$0	$0
CMS should reassess the risks and benefits of allowing in-home HRAs to be used as sources of diagnoses for risk adjustment and reconsider excluding such diagnoses from risk adjustment.
6506	No	$0	$0
CMS should require MAOs to flag any MAO-initiated HRAs in their MA encounter data.