OIG: Chart Reviews Fueled ‘Disproportionate’ MA Pay
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Oct 07, 2021
The HHS Office of Inspector General in prior reports has raised concerns about Medicare Advantage organizations’ heavy reliance on chart reviews and health risk assessments (HRAs) to achieve higher risk adjusted payments. Now, a new OIG report identifies multiple MAOs that have used those sources to a greater extent than their peers, leading the federal watchdog agency to suggest that CMS monitor companies with a disproportionate share of the risk-adjusted payments.
Report Tracked Unlinked Chart Reviews
MAOs may use both chart reviews — which are retrospective reviews of beneficiaries’ medical records — and HRAs — which may be conducted initially, annually and by a third-party vendor in the beneficiary’s home — to support diagnoses that they submit to the encounter data system for risk score determination. In a 2019 report, OIG raised concerns about MAOs’ use of unlinked chart reviews, referring to when diagnoses are added from chart reviews but did not link to a specific service record for the year, which applied to $2.7 billion out of $6.7 billion in risk adjusted payments for 2017. And OIG in September 2020 estimated that diagnoses reported only on HRAs in the encounter data resulted in $2.6 billion in risk adjusted payments for 2017, including $2.1 billion based on HRAs conducted in the home.
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