Medicare Advantage Payments Generated by Health Risk Assessments for 2023

Health risk assessments (HRAs) are conducted by physicians or other health care professionals to collect information about patients' health status, health risks, and daily activities. Prior OIG work has highlighted concerns about the extent to which Medicare Advantage Organizations (MAOs) use HRAs to improve care, as intended, and the sufficiency of oversight by CMS. This prior work found that diagnoses that MAOs reported only on HRAs-and on no other service records that year-resulted in an estimated $2.6 billion in risk-adjusted payments for 2017. OIG's findings raised concerns about the quality and coordination of care for enrollees, the validity of diagnoses reported on HRAs, and the appropriateness of payments generated by HRAs for 2017. For this data snapshot, we will determine the extent to which diagnoses reported only on HRAs (or added to HRAs by chart reviews) generated estimated riskadjusted payments for 2023. We also will determine whether enrollees with certain demographic characteristics were overrepresented among the enrollees who had diagnoses reported only on HRAs (or added to HRAs by chart reviews) that generated payments. Finally, we will interview CMS to identify the actions it has taken to address the impact of HRAs on Medicare Advantage payment integrity and quality of care.

Announced or Revised	Agency	Title	Component	Report Number(s)	Expected Issue Date (FY)
December 2023	Centers for Medicare and Medicaid Services	Medicare Advantage Payments Generated by Health Risk Assessments for 2023	Office of Evaluation and Inspections	OEI-03-23-00380	2025