The October 2024 Report on Health Risk Assessments from the Office of Inspector General (OIG) uncovered potential fraudulent payments for high-risk diagnoses.
Health Risk Assessments (HRAs) are utilized as part of the Annual Wellness Visit with a healthcare professional. HRAs are intended as a self-reported assessment included in the reconciliation during office, home, and telemedicine visits. Their purpose is to support providers in developing prevention plans to improve health status and delay the onset of chronic disease.
Concerns Arise from New OIG Report
In the OIG’s Office of Evaluation and Inspections report, concerns were raised about:
- The appropriateness of risk-adjusted payments generated by HRAs
Medicare Advantage (MA) companies may have submitted diagnoses on HRAs that were not documented in the enrollees’ medical records, potentially resulting in inappropriate payments from Centers of Medicare and Medicaid Services (CMS).
- The quality-of-care coordination for enrollees of those high-risk diagnoses
MA companies may not have coordinated care following these enrollees’ HRAs, including verifying that information was provided to the enrollees’ providers and ensuring appropriate follow-up care was delivered.
- The completeness of encounter data reported
MA companies may not have ensured that encounter data included all records of items and services provided to enrollees.
Previous OIG investigations indicated that chart reviews may allow MA companies to inflate risk-adjusted payments inappropriately. The OIG found that diagnoses reported solely from chart reviews—without corresponding service records in the encounter data—resulted in an estimated $6.7 billion in risk-adjusted payments for 2017.
In 2023, just 13 health conditions accounted for 75 percent of the estimated $7.5 billion in risk-adjusted payments from HRAs and HRA-linked chart reviews. The top five conditions were:
- Vascular disease: $967 million
- Major Depressive Disorder: $868 million
- Disorders of Immunity: $539 million
- Morbid Obesity: $479 million
- COPD: $409 million
What’s Changing
As a result of the OIG findings, CMS has been recommended to take the following action:
- Impose additional restrictions on the use of diagnoses reported only on in-home HRAs or chart reviews linked to in-home HRAs for risk-adjusted payments.
- Conduct audits to validate diagnoses reported only on in-home HRAs and HRA-linked chart reviews.
- Determine whether specific health conditions that drove payments from in-home HRAs and HRA-linked chart reviews may be more susceptible to misuse among MA companies.
It’s ultimately the provider’s responsibility for the documentation and plan of care in the encounter to ensure that compliant documentation is present to prevent fraudulent billing practice of Hierarchical Condition Categories (HCC) diagnoses.
A decline in over-documented conditions is expected with the establishment of the CMS Version 28 Risk Model.
Harmony Healthcare can help your organization navigate the changes CMS is making. Contact us to learn more about how we can support you.
For additional information, please refer to the following link: Medicare Advantage: Questionable Use of Health Risk Assessments Continues To Drive Up Payments to Plans by Billions, OEI-03-23-00380
