The Department of Health and Human Services, Office of Inspector General (OIG) continues to actively audit Medicare Advantage Risk Adjustment programs, with a focus on diagnosis codes at “high risk of being miscoded.” Between Feb. 2021 and May 2023, OIG issued 25 audit reports that uncovered significant issues.

Key findings from 25 OIG Risk Adjustment audits:

  • More than 145,000 “suspect” cases identified across Medicare Advantage contracts audited
  • Of 4,763 cases sampled, plans could only substantiate diagnosis codes in 27.9% of cases
  • Excluding two diagnosis classes, more than 90% of other sampled cases could not be validated
  • OIG estimated total overpayment exceed $427 million

ATTAC Risk Adjustment Solutions

#1. OIG Risk Adjustment Risk Assessment, powered by clinically driven Risk Adjustment analytics. The assessment:

  • Quickly helps plans quantify OIG Risk Adjustment risk, both in number of cases and dollar exposure
  • Covers all plan years from 2016 forward, adjusting for changes in coding and Risk Adjustment model
  • Relies on CMS standard file data and requires minimal plan effort

#2: ATTAC’s Risk Adjustment experts can help your plan rank and prioritize actions that will reduce the risk and aggravation of an OIG audit, through taking active steps to address previously filed Risk Adjustment data. We then help your plan establish preventive controls and monitoring to mitigate risk and optimize future Risk Adjustment performance.

**Special Offer for Health Plans** ATTAC will perform a no-cost / no-obligation Summary OIG RA Risk Assessment for the first 20 plans that contact us before August 31, 2023. The assessment report lists, by the OIG high-risk Dx codes, the number of member years a plan has that meet the OIG suspect criteria. Offer is limited to analyzing one H contract for one year. Contact us to claim this offer

Learn more about ATTAC’s OIG Risk Adjustment audits here.