The Office of Inspector General (OIG) found that some Medicare Advantage (MA) companies may be using health risk assessments (HRAs) and chart reviews to add diagnoses, potentially inflating risk adjusted payments without improving enrollee care.
In October 2024, the OIG released a report, OEI-03-23-00380, discussing the questionable use of HRAs in the MA program. The review stems from concerns that MA companies were improperly reporting unsupported diagnoses to inflate payments, costing taxpayers billions annually. The evaluation focused on 2022 MA encounter data which revealed that approximately 1.7 million enrollees had diagnoses reported solely from HRAs and chart reviews with a lack of follow-up care.
In-home HRAs and HRA-linked chart reviews accounted for nearly two-thirds of the inflated payments, primarily driven by just 20 MA companies that made up 80% of the total. The findings raised questions about the accuracy of these diagnoses and the quality of care provided to enrollees.
The OIG recommended that the Centers for Medicare & Medicaid Services (CMS) impose additional restrictions on diagnoses reported solely from in-home HRAs, which could exclude them from risk-adjusted payments unless there is evidence of meaningful follow-up care. The OIG also called for improved oversight including audits to validate home diagnoses.
The CMS acknowledged the concerns but disagreed with some OIG recommendations, particularly regarding imposing restrictions on in-home HRAs and conducting audits.
Also known as Medicare Part C, the MA program is a health insurance option offered by private insurance companies that contract with Medicare to provide Medicare beneficiaries with an alternative to traditional Medicare (Parts A and B). Under the program, these beneficiaries receive all their Medicare covered health services through these private plans.
The CMS stated, “CMS is committed to ensuring that diagnoses that Medicare Advantage (MA) organizations submit for risk adjustment, including those associated with Health Risk Assessments (HRAs) conducted in the home, are accurate, and can be validated through medical record reviews. CMS has already taken action to target plans at higher risk for improper payment… CMS appreciates the OIG’s review in this area and will continue to consider the relationship of HRAs to the care provided to beneficiaries. CMS’s specific responses to the OIG’s recommendations are contained within the OIG report.”
The HHS OIG press representative provided their view on the next steps beyond the report, “In terms of our report follow-up process, CMS’s final management decisions and actions plans for our recommendations are due to OIG six months from our final report issuance (i.e., in April 2025 for this report). We will also continue to communicate our concerns about the misuse of health risk assessments – and make the case for better compliance by industry and stronger program safeguards – to CMS and other stakeholders.
In addition, this report is part of a larger portfolio of OIG work focused on this issue and others to protect the integrity of Medicare Advantage payments and the health and well-being of MA enrollees.”
While HRAs have the potential to connect individuals to necessary services based on health needs, they also influence how risk adjusted payments are calculated. These payments can increase when specific diagnoses are reported, particularly those found during in home HRAs. The practice brings concerns about these MA companies potentially focusing on maximizing payments rather than genuinely improving care.
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HRAs are surveys used by MA plans to identify health risks and guide care.
The OIG oversees and investigates potential fraud, waste, and abuse in Medicare and other federal programs.