Medicare Advantage: Questionable Use of Health Risk Assessments Continues To Drive Up Payments to Plans by Billions

Date Issued

Monday, October 21, 2024

Submitting OIG

Department of Health & Human Services OIG

Agencies Reviewed/Investigated

Department of Health & Human Services

Report Number

OEI-03-23-00380

Report Type

Inspection / Evaluation

Agency Wide

Yes

Number of Recommendations

Questioned Costs

Funds for Better Use

Report updated under NDAA 5274

External Link

Open Recommendations

This report has 3 open recommendations.

Recommendation Number	Significant Recommendation	Recommended Questioned Costs	Recommended Funds for Better Use
25-E-03-003.01	No	$0	$0
CMS should 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. While there are general requirements and oversight in place for the MA risk adjustment payment.
25-E-03-003.02	No	$0	$0
CMS should conduct audits to validate diagnoses reported only on in-home HRAs and HRA-linked chart reviews.
25-E-03-003.03	No	$0	$0
CMS should determine whether select HCCs that drove payments from in-home HRAs and HRA-linked chart reviews may be more susceptible to misuse among MA companies.