BC Advantage - 2021 Issue 5

OIG Plans for Onslaught of Risk Adjustment Audits Claiming 9.5% Error Rate in Code Assignment

According to an Office of The Inspector General Report, the Centers for Medicare & Medicaid Services (CMS) estimate that 9.5% of all payments to Medicare Advantage organizations are improper due to unsupported diagnoses submitted by the organizations themselves. Medicare Advantage Organizations (MAOs) receive funding based on ICD-10-CM reporting specific to the individual Medicare beneficiary enrolled in the MAO. A patient who is healthy will likely not require as many medical services as a beneficiary with poor health conditions or comorbidities. Barring unexpected injury or illness, healthier patients are less likely to experience hospital admissions, frequent physician encounters...

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