Federal Reports

The SEC Has Taken Steps to Strengthen Its Monitoring of ISS Contractor’s Performance, But Additional Actions Are Needed, Report No. 565

Under the Medicare Advantage (MA) program, the Centers for Medicare & Medicaid Services (CMS) makes 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 enrollees with diagnoses associated with more intensive use of health care resources than to healthier enrollees, who would be expected to require fewer health care resources.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.For this audit, we reviewed one MA organization, Blue Cross Blue Shield of Michigan (BCBSM), and focused on seven groups of high-risk diagnosis codes. Our objective was to determine whether selected diagnosis codes that BCBSM submitted to CMS for use in CMS's risk adjustment program complied with Federal requirements.

We investigated allegations that a tribal non-profit organization misused $50,000 it received for a 3-day training conference. It received the funds from the Bureau of Indian Affairs (BIA) through a cooperative agreement.We did not find any evidence of misuse of funds or of false claims and determined the organization used the full amount of the cooperative agreement to cover costs associated with the training conference.