By Sandra Durkin

In a report issued in October 2024, the Office of Inspector General (“OIG”) within the Department of Health and Human Services (“HHS”) expressed concern that health risk assessments (“HRAs”) and chart reviews used by Medicare Advantage organizations (“MAOs”) are being misused to drive up payments from the government, rather than to improve member care.

OIG’s concern is not new, nor is it isolated. OIG has been claiming that HRAs and chart reviews are vulnerable to misuse for years, including in reports issued in 2019, 2020 and 2021,and has persistently questioned whether HRAs should be used as a source of diagnoses for risk adjustment. OIG’s reports have received wide media coverage, which, in turn, drives calls to reform how MAOs are paid, such as the proposed “No Unreasonable Payments, Coding, or Diagnoses for the Elderly (‘No UPDCODE’) Act.”

One aspect of OIG’s oversight of the MA risk adjustment program that is often overlooked in the public discourse is that HRAs are an important tool for MAOs to provide member care—one that is specifically encouraged by the Centers for Medicare & Medicaid Services (“CMS”). Specifically, HRAs allow MAOs to assess member health risks early and develop a plan of care that prevents them from becoming more serious (and expensive to treat) in the future. In-home HRAs in particular allow MAOs to evaluate the environmental factors that may affect a member’s health. Without HRAs, MAOs would not have a complete picture of their members health needs.

This is one of several reasons that CMS considers diagnoses gathered in connection with an HRA when calculating payments to MAOs. It is also the reason CMS has consistently disagreed with OIG recommendations to curtail the use of HRAs.

In the most recent OIG report, OIG recommended that CMS (1) impose additional restrictions on the use of diagnoses reported only on in-home HRAs (or chart reviews that are linked to in-home HRAs) for risk-adjusted payments. CMS specifically disagreed with this recommendation, pointing out that OIG did not conduct medical record reviews of any of the diagnoses that were gathered in connection with an HRA, and did not conclude that any of the challenged diagnoses were in fact unsupported or inaccurate. CMS already conducts audits of diagnoses submitted for risk adjustment (including those linked to an HRA) as part of the Risk Adjustment Data Validation (“RADV”) audit process.

OIG also recommended that CMS (2) conduct audits to validate diagnoses reported only on in-home HRAs (and HRA-linked chart reviews). OIG also recommended that CMS (3) determine whether select health conditions that drove payments from in-home HRAs (and HRA-linked chart reviews) may be more susceptible to misuse among MA companies. As to (2), CMS agreed that it will look at diagnoses gathered during HRAs as part of future RADV audits. As to (3), CMS pointed out that it has already implemented this recommendation and considers it closed.

In this environment, MAOs must demonstrate that HRA and chart review programs support the delivery of quality care to members. OIG’s findings in regard to the role that HRAs play in care delivery are significant. OIG found that 1.7 million MA enrollees had diagnoses that were reported only on HRAs (or HRA-linked chart reviews) and that, of those, thousands of enrollees had no service records at all in 2022 besides a single HRA. This suggests that these enrollees did not receive any follow-up care for the conditions reported on the HRAs.

To ensure that members receive necessary follow-up care, whether it be visits, procedures, tests, or supplies, MAOs should adhere to CMS’s recommended best practices when conducting HRAs. These include:

• Scheduling appointments with appropriate providers;
• Making referrals to appropriate community resources;
• Verifying that needed follow-up care is provided;
• Verifying that information obtained during the assessment is provided to the appropriate providers;
• Providing summaries to enrollees that include their diagnoses, medications, scheduled follow-up appointments, plans for care coordination, and contact information for community resources; and
• Placing enrollees in disease management or case management programs, as appropriate.

See CMS, “Announcement of Calendar Year (CY) 2016 MA Capitation Rates and MA and Part D Payment Policies and Final Call Letter,” p.146.

Additionally, MAOs must be sure that all materials—whether internal or outward-facing—reflect the proper role of HRAs in an MAOs risk adjustment program. In particular, contracts and communications with providers and risk adjustment vendors should make clear that the HRA is a tool for delivering quality member care.

For additional information putting the OIG’s recent report in context, please see the response published by AHIP.