Testimony Before the  
United States House Committee on Energy and Commerce 
Subcommittee on Oversight and Investigations 
 
 
 
 
Protecting Americas Seniors: Oversight of  
Private Sector Medicare Advantage Plans  
 
Testimony of: 
Erin Bliss 
Assistant Inspector General  
Office of Evaluation and Inspections 
Office of Inspector General  
Department of Health and Human Services 
 
 
 
 
June 28, 2022 
11 a.m. 
2123 Rayburn House Office Building  
Testimony of: 
Erin Bliss 
Assistant Inspector General for Evaluation and Inspections 
Department of Health and Human Services, Office of Inspector General 
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Good morning, Chair DeGette, Ranking Member Griffith, and distinguished Members of the 
Subcommittee.  I am Erin Bliss, Assistant Inspector General for Evaluation and Inspections, at 
the Department of Health and Human Services (HHS), Office of Inspector General (OIG).  
Thank you for the opportunity to appear before you today to discuss oversight of Medicare 
Advantage plans. 
In 2021, approximately 26 million Medicare beneficiaries (more than 40 percent) were enrolled 
in Medicare Advantage plans, continuing a trend of significant growth in Medicare Advantage 
enrollment.1  One of OIGs top priorities is ensuring that the Medicare Advantage program 
works effectively and provides quality care for enrollees and value for taxpayers.  This priority 
includes ensuring that Medicare Advantage enrollees have access to appropriate and medically 
necessary care and that payments to Medicare Advantage organizations (MAOs) are based on 
accurate information about their enrollees health conditions. 
Today, I will focus my testimony on two lines of OIG evaluations aimed at advancing those 
goals.  In summary, we have identified the following concerns: 
  MAOs sometimes delayed or denied beneficiaries access to medical services, even 
though the requested care was medically necessary and met Medicare coverage rules.  
In other words, these Medicare Advantage beneficiaries were denied access to needed 
services that likely would have been approved if the beneficiary had been enrolled in original 
Medicare.  These denials likely prevented or delayed needed care for beneficiaries.  In 
addition, MAOs sometimes denied payments to health care providers for services that they 
had already delivered to patients, even though the requests met Medicare coverage rules and 
MAO billing rules and should have been paid by the plan. 
 
  MAOs received an estimated $9.2 billion in payments in 2017 for beneficiary diagnoses 
reported solely on chart reviews or health risk assessments, with no other records of 
services for those diagnoses in the encounter data.  This finding raises three concerns: (1) 
payment integrityif the diagnoses were inaccurate, then MAOs received inappropriate 
payments; (2) quality of careif the diagnoses were accurate, then beneficiaries may not 
have received appropriate care to treat these often serious conditions; and (3) data integrity
if the diagnoses were accurate and beneficiaries received care, then MAOs may not have 
reported all provided services in the encounter data as required.  
 
1 Kaiser Family Foundation, Medicare Advantage in 2021: Enrollment Update and Key Trends, June 2021.  
2 
   
In my testimony, I will provide further details and context on these findings and highlight the 
actions that OIG has recommended the Centers for Medicare & Medicaid Services (CMS) take to 
better ensure that Medicare Advantage beneficiaries have timely access to all necessary health 
care services, that providers are paid appropriately, and that MAOs do not inappropriately inflate 
their risk-adjustment payments by reporting inaccurate diagnoses. 
MEDICARE ADVANTAGE DENIALS OF SERVICES AND PAYMENTS 
OIGs most recent report on Medicare Advantage examined MAO denials of requests for prior 
authorization, which is preapproval for a service or item before the beneficiary receives it, and 
denials of payment requests from a provider for a service already delivered to the beneficiary.2  
Why Focus Oversight on Medicare Advantage Denials 
Incentives.  A central concern about capitated payment models, including Medicare Advantage, 
is the potential incentive for insurers to deny access to services for enrollees and deny payments 
to providers to increase profits.  MAOs are paid a fixed amount of money each month for each 
enrollee, regardless of the number or cost of services they pay for on behalf of that enrollee.   
Volume of Denials.  Although MAOs approve the vast majority of requests for services and 
payment, they issue millions of denials each year.  In 2018, MAOs denied 1.5 million prior 
authorization requests (5 percent of all prior authorization requests) and 56.2 million payment 
requests overall (9.5 percent of all payment requests) in the Medicare Advantage program. 
Prior Evidence of Problems.  OIGs previous analysis of Medicare Advantage appeals 
outcomes raised concerns about MAO denials.3  When beneficiaries and providers appealed 
service and payment denials, MAOs overturned 75 percent of their own denials during 2014
2016.  Independent reviewers at higher levels of the appeals process overturned additional 
denials in favor of beneficiaries and providers.  The high rate of overturned denials raises 
concerns that some beneficiaries and providers were initially denied services and payments that 
should have been provided.  This is especially concerning because beneficiaries and providers 
appealed only 1 percent of denials.  In addition, OIG found that CMSs annual audits of MAOs 
from 2012 through 2016 commonly identified problems related to denials. 
How OIG Assessed Medicare Advantage Denials 
For our most recent report, we selected a stratified random sample of 250 denials of prior 
authorization requests and 250 payment denials issued by 15 of the largest MAOs by enrollment 
during June 17, 2019.4  Health care coding experts reviewed case files for all cases, and 
 
2 OIG, Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About 
Beneficiary Access to Medically Necessary Care, (OEI-09-19-00260), April 2022. 
3 OIG, Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns about Service and Payment 
Denials, (OEI-09-16-00419), September 2018.  
4 These 15 MAOs accounted for nearly 80 percent of Medicare Advantage enrollees. 
3 
   
physician reviewers examined medical records for a subset of cases that warranted medical 
necessity review.  From these results, we estimated the rates at which MAOs denied prior 
authorization and payment requests that met Medicare coverage rules and MAO billing rules.5  
We also examined the reasons for these denials in our sample. 
OIG Findings Raise Concerns About MAO Denials of Services 
Among prior authorization requests that MAOs denied, 
13 percent were for requests that met Medicare coverage 
rules.  In other words, these services likely would have 
13% 
of prior authorization  been approved in original Medicare.  This rate projects to 
1,631 prior authorization denials for requests that met 
denials were for services that 
Medicare coverage rules for these MAOs during the first 
met Medicare coverage rules  week of June 2019.6  Such denials can have a range of 
negative impacts, such as 
beneficiaries not receiving 
needed care, delays in receiving needed care, beneficiaries 
IMPACT: Denials likely 
receiving an alternative service that may be less effective for their 
prevented or delayed 
needs, beneficiaries paying out-of-pocket for care, and/or 
administrative burden for beneficiaries or their providers who  needed care 
choose to appeal the denial. 
MAO use of internal clinical criteria contributed to many of these denials in our sample.  
For many of the denials of prior authorization requests in our sample for services that met 
Medicare coverage rules, MAOs denied the requests by applying MAO clinical criteria that are 
not required by Medicare.  MAOs must follow Medicare coverage rules, which specify what 
items and services are covered and under what circumstances.  However, they are also permitted 
to use additional clinical criteria that were not developed by Medicare, as long as such criteria 
are no more restrictive than original Medicares national and local coverage policies.7 
CMS guidance on the appropriate use of such criteria is insufficient.  In several cases, we 
were unable to determine whether the prior authorization denials that met Medicare coverage 
rules would be considered appropriate by CMS because CMSs guidance regarding MAO use of 
internal clinical criteria is not sufficiently detailed.  The following example illustrates why more 
guidance and clarity is needed to apply this requirement. 
 
 
5 Our sampling method enables us to project these rates to the universe of all denials by the 15 largest MAOs during 
this time period.  However, it does not enable us to estimate MAO-specific rates or to project the reasons for denials 
from our sampled cases to the universe of denials. 
6 For an annual context, if these MAOs denied the same number of prior authorization requests in each week of 
2019, they would have denied 84,812 beneficiary requests for services that met Medicare coverage rules that year. 
7 CMS, Medicare Managed Care Manual, chapter 4, section 10.16, p. 28. 
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Denial of CT Scan Illustrates Why More Guidance Is Needed on Use of MAO Clinical Criteria 
An MAO denied a prior authorization request for a computed tomography (CT) scan that our physician 
reviewers determined was medically necessary to exclude a life-threatening diagnosis (aneurysm) 
based on the beneficiarys symptoms and comorbidities.  The MAO stated that its clinical criteria 
required the beneficiary to have an x-ray first to prove that a CT scan was needed. 
Medicares coverage policy for CT scans states: [T]here is no general rule that requires other 
diagnostic tests to be tried before CT scanning is used.  
One might conclude that the MAO criteria in this case was more restrictive than the Medicare 
coverage policy and thus not allowable.  However, CMS officials reported to OIG that MAOs may 
establish additional clinical criteria for Medicare-covered services, as long as the criteria are evidence-
based and do not contradict the applicable Medicare coverage rules.  In this example, the denial 
might be considered allowable if CMS judged that the MAOs x-ray requirement was evidence-based 
and did not contradict the Medicare coverage policy for CT scans. 
 
 
 
Other prior authorization denials in our sample resulted from MAO requests for unnecessary 
documentation.  In some of these cases, MAOs requested copies of documentation already 
contained in the case file. 
OIG Findings Raise Concerns About MAO Denials of Payments 
An estimated 18 percent of payment denials met Medicare 
coverage rules and MAO billing rules and therefore the 
18%  provider payments should not have been denied by the 
of payment denials 
MAOs.  This projects to 28,949 payment denials that met 
Medicare coverage rules and MAO billing rules for these 
were for claims that met 
MAOs during the first week 
Medicare coverage rules and  of June 2019.8  Denying 
MAO billing rules  payment requests that meet 
IMPACT: Denials prevented or 
Medicare and MAO rules 
delayed payments to providers 
delays or prevents providers 
from receiving payment for services that they have already  for services already delivered 
delivered to beneficiaries. 
Human errors during manual reviews contributed to these payment denials.  MAOs rely on 
their staff to manually review some requests for payments before approving or denying them. 
 
8 For an annual context, if these MAOs denied the same number of payment requests each week of 2019, they would 
have denied 1.5 million payment requests that met Medicare coverage rules and MAO billing rules that year. 
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These reviews are susceptible to human error, such as a reviewers overlooking a document in 
the case file or inaccurately interpreting CMS or MAO coverage rules.  
System programming errors also contributed to payment denials.  MAOs denied some 
payment requests because of inaccurate programming of claims processing systems.  System 
errors can cause greater harm because they could generate large volumes of incorrect denials 
until the MAO notices and fixes the error. 
OIG Recommends Ways for CMS To Better Protect Beneficiaries and 
Providers From Inappropriate Denials 
We have recommended that CMS take the following actions to ensure that beneficiaries have 
timely access to all necessary health care services, and that providers are paid appropriately: 
  issue new guidance on the appropriate use of MAO clinical criteria in medical 
necessity reviews, 
 
  incorporate the issues identified in our evaluation into its audits of MAOs, and 
 
  direct MAOs to take additional steps to identify and address vulnerabilities that can 
lead to manual review errors and system errors. 
CMS agreed with each of these recommendations and indicated that it plans to implement them. 
In addition, two of OIGs recommendations remain open from our 2018 report on outcomes of 
Medicare Advantage appeals.  These recommendations are that CMS: 
  enhance its oversight of MAO contracts, including those with extremely high 
overturn rates and/or low appeal rates, and take corrective action as appropriate, 
and 
 
  provide beneficiaries with clear, easily accessible information about serious 
violations by MAOs.   
Although CMS agreed with these recommendations, it has not yet fully implemented them.  
CMS implemented our third recommendation from that 2018 report.  In 2019, CMS revised its 
Civil Money Penalty Calculation Methodology to include a new aggravating factor for 
inappropriate delay or denial of medical services, drugs, and/or appeal rights, and new 
aggravating factors for prior offensesall changes that better hold MAOs accountable for 
ensuring appropriate access to care. 
 
 
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USE OF CHART REVIEWS AND HEALTH RISK ASSESSMENTS 
OIG has issued a series of evaluations examining the financial impacts of chart reviews and 
health risk assessments on Medicare Advantage risk-adjustment payments.9  Risk adjustment is a 
mechanism to increase payments to MAOs for covering sicker beneficiaries based on beneficiary 
diagnoses.  Chart reviews and health risk assessments are ways that MAOs can identify and add 
diagnoses to the data they submit to CMS for their beneficiaries, which may increase the 
payments they receive. 
Chart Reviews: Retrospective reviews of beneficiaries medical record documentation to 
identify and add diagnoses that providers did not originally submit to the MAO and to 
delete any invalid diagnoses. 
Health Risk Assessments: Health care professionals collect information from beneficiaries 
about their health status, health risks, and daily activities.  Some MAOs contract with 
vendors to visit beneficiaries in their homes to conduct these assessments.  Health risk 
assessments are meant to improve care and support care coordination.  
 
Why Focus Oversight on Chart Reviews and Health Risk Assessments 
Incentives.  Although risk adjustment is an important mechanism to help ensure that 
beneficiaries who need a costlier level of care have continued access to MA plans, it may also 
create financial incentives for MAOs to make beneficiaries appear as sick as possible to increase 
these payments.  Most beneficiary diagnoses are submitted by treating providers to MAOs.  
However, chart reviews and health risk assessments offer ways for MAOs to add diagnoses to 
the data CMS uses for risk adjustment more directly (i.e., through chart reviews) or indirectly 
(e.g., through a vendor conducting health risk assessments for the MAO).  
Inappropriate Risk-Adjustment Payments.  CMS reported a payment error rate of 10.3 
percent for Medicare Advantage risk-adjustment payments in FY 2021, which resulted in net 
overpayments of almost $7.2 billion.10  Through two series of compliance audits, OIG has 
questioned costs related to the diagnosis codes that MAOs submit to CMS.  One OIG series of 
audits involves sampling from all diagnosis codes submitted by a plan, and OIGs completed 
audits of two plans have identified questioned costs of $252 million.11  The other OIG series is 
 
9 OIG, Billions in Estimated Medicare Advantage Payments From Chart Reviews Raise Concerns, OEI0317-
00470, December 2019; OIG, Billions in Estimated Medicare Advantage Payments From Diagnoses Reported Only 
on Health Risk Assessments Raise Concerns, OEI-03-17-00471, September 2020; OIG, Some Medicare Advantage 
Companies Leveraged Chart Reviews and Health Risk Assessments To Disproportionately Drive Payments, OEI-03-
17-00474, September 2021. 
10 CMS, Part C Improper Payment Measure Fiscal Year 2021 Payment Error Rate Results.   
11 OIG, Medicare Advantage Compliance Audit of Diagnosis Codes That Humana, Inc., (Contract H1036) 
Submitted to CMS, A-07-16-01165, April 2021; OIG, Medicare Advantage Compliance Audit of Diagnosis Codes 
That SCAN Health Plan (Contract H5425) Submitted to CMS, A-07-17-01169, January 2022. 
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targeting specific diagnosis codes.  We have completed 8 targeted audits in this series with total 
questioned costs of $37.4 million.12  We have additional audits underway for both series.  
Finally, in a recent investigation of a provider that OIG conducted with the Department of 
Justice, Sutter Health and its affiliates agreed to pay $90 million and enter into a corporate 
integrity agreement with OIG to settle False Claims Act allegations that it knowingly submitted 
unsupported diagnoses for beneficiaries in Medicare Advantage plans, resulting in inflated risk-
adjustment payments.13  
Prior Concerns About Chart Reviews and Health Risk Assessments.  OIGs work builds on 
concerns raised by other oversight entities.  In 2016, the Government Accountability Office 
(GAO) raised concern that diagnoses collected from MAOs chart reviews may be less likely to 
be supported by medical records than diagnoses submitted to MAOs by providers.14  CMS and 
the Medicare Payment Advisory Commission (MedPAC) have questioned whether MAOs use 
health risk assessments primarily as a strategy to submit more diagnoses to increase payments 
rather than to improve the care provided to their beneficiaries.  Since 2016, MedPAC has 
recommended that HHS eliminate health risk assessments as a source of diagnoses for risk-
adjustment payments.15  
How OIG Assessed the Financial Impact of Chart Reviews and Health Risk Assessments 
We analyzed Medicare Advantage encounter data from 2016 to identify diagnoses that were 
included solely on chart reviews or health risk assessments and not on any other records of 
services for beneficiaries during that year.  We then calculated how much these diagnoses 
increased the 2017 risk-adjustment payments to those MAOs.  We also compared across MAOs 
to determine whether any MAOs use of chart reviews and health risk assessments increased 
their risk-adjustment payments disproportionately relative to their size and their peers. 
 
12 Some Diagnosis Codes That Essence Healthcare, Inc., Submitted to CMS Did Not Comply With Federal 
Requirements, A-07-17-01170, April 2019; OIG, Medicare Advantage Compliance Audit of Specific Diagnosis 
Codes That Blue Cross Blue Shield of Michigan (Contract H9572) Submitted to CMS, A-02-18-01028, February 
2021; OIG, Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Anthem Community Insurance 
Company, Inc. (Contract H3655) Submitted to CMS, A-07-19-01187, May 2021; OIG, Medicare Advantage 
Compliance Audit of Specific Diagnosis Codes That Coventry Health Care of Missouri, Inc. (Contract H2663) 
Submitted to CMS, A-07-17-01173, October 2021; OIG, Medicare Advantage Compliance Audit of Specific 
Diagnosis Codes That UPMC Health Plan, Inc. (Contract H3907) Submitted to CMS, A-07-19-01188, November 
2021; OIG, Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Healthfirst Health Plan, Inc., 
(Contract H3359) Submitted to CMS, A-02-18-01029, January 2022; OIG, Medicare Advantage Compliance Audit 
of Specific Diagnosis Codes That Tufts Health Plan (Contract H2256) Submitted to CMS, A-01-19-00500, February 
2022; OIG, Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Peoples Health Network 
(Contract H1961) Submitted to CMS, A-06-18-05002, May 2022. 
13 DOJ, Sutter Health and Affiliates to Pay $90 Million to Settle False Claims Act Allegations of Mischarging the 
Medicare Advantage Program, August 30, 2021.   
14 GAO, Fundamental Improvements Needed in CMSs Effort to Recover Substantial Amounts of Improper 
Payments, GAO-16-76, April 2016, p.13. 
15 As part of this recommendation, MedPAC recommended that the Secretary develop a risk-adjustment model that 
uses 2 years of Medicare fee-for-service and MA diagnostic data.  See MedPAC, Report to the Congress: Medicare 
Payment Policy, March 2016, p. 352. 
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OIG Findings Raise Concerns About MAOs Use of Chart Reviews and 
Health Risk Assessments 
For 16.8 million chart reviews (41 
$6.7 Billion 
percent), there were no service records 
in payments to MAOs 
of visits, procedures, tests, or supplies 
were generated by diagnoses only on chart  that contained the diagnosis reported on 
the chart review.  These 16.8 million 
reviews and not on any service records 
chart reviews corresponded to 
4.5 million beneficiaries (MAOs can 
submit multiple chart reviews for the 
same beneficiaries).  This means that, for the entire year, these beneficiaries may not have 
received any other services for the medical conditions indicated by the diagnoses.  However, 
Medicare paid MAOs an estimated $6.7 billion in risk-adjustment payments in 2017 arising from 
these chart review diagnoses to provide care for these beneficiaries. 
Although chart reviews are intended to strengthen payment accuracy by both adding missing 
diagnoses and deleting invalid diagnoses, MAOs almost exclusively added diagnoses.  Only 
0.7 percent of chart reviews deleted diagnoses, while 99.3 percent added diagnoses. 
Of these payments from chart reviews, an estimated $2.7 billion were driven by unlinked 
chart reviews, which may be more vulnerable to misuse.  To be eligible for risk-adjustment 
payments, a diagnosis must be documented based on a visit with an eligible health care provider.  
Linked Chart Review: Points to a record of service that the beneficiary received from a 
health care provider as being the source of the medical documentation to support the newly 
added diagnosis. 
Unlinked Chart Review: Does not indicate what health care visit or service was the source of 
the medical documentation that supports the newly added diagnosis.  
Unlinked chart reviews do not indicate what visit or service the diagnosis came from and often 
contain default or dummy procedure codes, which would make it difficult to use encounter 
data to validate whether the diagnosis is eligible for payment.  
Many of these unlinked charted reviews added diagnoses for serious and chronic 
conditions, despite the beneficiaries having no records for services indicating these 
conditions.  Common conditions from these unlinked reviews were vascular disease; diabetes 
with chronic complications; chronic obstructive pulmonary disease; congestive heart failure; and 
major depressive, bipolar, and paranoid disorders.  
 
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MAOs reported diagnoses on health risk 
$2.6 Billion 
assessments for 3.5 million beneficiaries 
in payments to MAOs 
with no other encounter records of visits, 
were generated by diagnoses only on  procedures, tests, or supplies that contained 
the diagnosis reported on the assessment.  
health risk assessments and not on any 
These diagnoses resulted in an estimated 
other service records 
$2.6 billion in risk-adjustment payments for 
2017. 
For the entire year, these beneficiaries may not have received other services for the medical 
conditions indicated by the diagnoses from their health risk assessments.  This raises 
questions about whether these assessments were administered as part of a care plan that included 
care coordination as intended.  When health risk assessments lack care coordination, such as 
providing information to beneficiaries primary care providers and ensuring that beneficiaries 
receive needed treatment, they could become vehicles for MAOs to collect diagnoses rather than 
function as tools to improve beneficiary health.   
In-home health risk assessments, which may be more vulnerable to misuse, generated 
80 percent of the estimated payments from diagnoses reported only on health risk 
assessments.  Health risk assessments are often conducted in a doctors office as part of a 
wellness visit but may be conducted in 
beneficiaries homes.  In-home health risk 
assessments represented only one-third of the  In-home health risk assessments: 
assessments we reviewed but accounted for  comprised 33% of assessments 
80 percent of the increased payments from 
led to 80% of risk-adjustment payments 
their resulting diagnoses.  Most of these in-
home health risk assessments that resulted in 
increased payments were conducted by vendors on behalf of MAOs.  The lack of other encounter 
records that contain the diagnoses identified by these vendors raises questions about whether the 
MAOs ensured that the results of these assessments were forwarded to beneficiaries primary 
care providers; beneficiaries received appropriate followup care and treatment; and the diagnoses 
reported only on in-home health risk assessments were accurate. 
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Diagnoses from chart reviews or health risk assessments onlywith no other 
service recordsraise three important concerns. 
Payment Integrity: Some of these diagnoses may have been inaccurate and resulted in 
improper payments. 
Quality of Care: Some of these beneficiaries may have had these often-serious 
diagnoses and may not have received needed care. 
Data Integrity: Some beneficiaries may have had these diagnoses and received care, but 
MAOs did not submit all service records as required, which hinders oversight. 
 
 
 
Of the 162 MAOs with any 
20 of 162 MAOs
:  risk-adjustment payments 
resulting solely from chart 
Accounted for 54% of payments ($5 billion) solely 
reviews or health risk 
from chart reviews or health risk assessments  assessments, 20 had a share 
of payments that was 
despite covering only 31% of beneficiaries in MA 
disproportionally higher than 
their size (defined by their 
share of enrolled 
beneficiaries).  These 20 MAOs generated 54 percent ($5.0 billion) of the estimated $9.2 billion 
in total payments from diagnoses submitted solely on chart reviews and health risk assessments 
but enrolled only 31 percent of Medicare Advantage beneficiaries.  Payments for 10 of these 20 
MAOs were also disproportionately driven by unlinked chart reviews and in-home health risk 
assessmentseach of which may be more vulnerable to misuse. 
One MAO stood out from its peers in its use of chart reviews and health risk assessments to 
drive risk-adjustment payments.  Among the top 20 MAOs, one MAO generated 40 percent 
($3.7 billion of $9.2 billion) of all payments from diagnoses submitted solely on chart reviews 
and health risk assessments, yet it enrolled only 22 percent of all MA beneficiaries.  Further, this 
MAO accounted for two-thirds of all payments resulting from in-home health risk assessments. 
 
 
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OIG Recommends Ways for CMS To Better Ensure Appropriate Payments to 
MAOs and Quality of Care for Enrollees 
To better ensure appropriate MAO payments and patient quality of care, we have made several 
specific recommendations to CMS that address three key actions needed: 
  conduct targeted oversight of MAOs that are driving a high or disproportionate 
share of payments from chart reviews and/or health risk assessments, 
 
  reassess the risks and benefits of allowing unlinked chart reviews and in-home 
health risk assessments to be used as sources of diagnoses for risk-adjustment 
payments, and 
 
  require MAOs to implement best practices for care coordination for beneficiaries 
who receive health risk assessments. 
 
CMS has either implemented or taken steps to implement some of OIGs recommendations.  
CMS followed up with MAOs that had payments resulting from unlinked charts for beneficiaries 
who had no other service records in all of 2016.  In addition, CMS has taken steps to include 
chart reviews in its audits that validate diagnoses for risk adjustment.   
CMS has agreed to some additional recommendations but has not yet implemented them.  These 
recommendations include providing targeted oversight of the MAOs that drove most of the risk-
adjustment payments resulting from in-home health risk assessments. 
CMS has disagreed with some of OIGs recommendations.  These include recommendations to 
require MAOs to implement best practices for care coordination, to flag MAO-initiated health 
risk assessments in their MA encounter data, and to reassess the risks and benefits of allowing 
in-home health risk assessments to be used as the source of diagnoses for risk-adjustment 
payments.  
OIG will continue to follow up with CMS on all our open recommendation to press for better 
safeguards over billions of dollars in Medicare Advantage risk-adjustment payments and to 
ensure that beneficiaries in Medicare Advantage receive the care that they need. 
CONCLUSION  
As Medicare Advantage enrollment continues to grow, MAOs play an increasingly critical role 
in ensuring that Medicare beneficiaries have appropriate access to needed care and that providers 
are reimbursed appropriately.  It is also vital that MAOs submit accurate information about the 
diagnoses that drive billions of dollars in risk-adjustment payments.  However, our evaluations 
raise concerns about how MAOs fulfill these critical responsibilities that affect beneficiary health 
and the value of taxpayer investments in the program. 
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Denied service requests that meet Medicare coverage rules may prevent or delay beneficiaries 
from receiving medically necessary care and can burden providers.  Even when denials are 
reversed, avoidable delays and extra steps create friction in the program and may create an 
administrative burden for beneficiaries, providers, and MAOs.  Further, beneficiaries enrolled in 
Medicare Advantage may not be aware that they may face greater barriers to accessing certain 
types of health care services in Medicare Advantage than in original Medicare. 
At the same time, MAOs have the potential to inappropriately increase risk-adjustment 
paymentsand thus, taxpayer costsif they misuse chart reviews and health risk assessments.  
Diagnoses that show up solely on those reviews and assessments could also signal that some 
beneficiaries are not receiving services they may need to treat serious conditions.  
It is critical that CMS take action to better ensure that Medicare Advantage beneficiaries have 
timely access to all necessary health care services, that providers are paid appropriately, and that 
MAOs do not inappropriately inflate their risk-adjustment payments.  We have recommended 
several ways for CMS to do this and will continue to push for progress.  OIG will also continue 
to be vigilant in our oversight work to promote payment integrity, beneficiary access, and quality 
of care in Medicare Advantage. 
We appreciate the attention that the Subcommittee is bringing to these important issues and the 
opportunity to testify before you today.  I welcome your questions.   
13