HCC Blog by Caridad

CMS has released their Advanced Notice for CY 2023. Highlights for risk adjustment include: Section G. CMS-HCC Risk Adjustment Model for CY 2023          page 42 For CY 2023, CMS will continue to calculate 100 percent of the risk score using the 2020 CMSHCC model, which we began phasing in with CY 2020 payment as described in Part I of the CY 43 2020 Advance Notice.10 The 2020 CMS-HCC model complies with the revisions to the risk adjustment for MA payments required by section 1853(a)(1)(I) of the Act, as amended by the 21st Century Cures Act.  Section M. Sources of Diagnoses for Risk Score Calculation for CY 2023 Page 67 then Attachment III, Section A. RxHCC Risk Adjustment Model     Page 68   Advance Notice of Methodological Changes for Calendar Year (CY) 2023 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies (cms.gov) 159 pages

An audit summary report from the Office of Inspector General (OIG) Medicare Advantage Compliance Audit of Diagnosis Codes That SCAN Health Plan Submitted to CMS Date of report 02/03/2022 For this audit the OIG reviewed the diagnosis codes submitted by SCAN Health Plan from claims from 2015. Yes, the review was on claims for the year 2015. Highlights from the report include: Sample set was 200 enrollees. Per the OIG, 164 HCCs were not validated and resulted in overpayments The OIG estimated that SCAN received at least $54.3 million in net overpayments for 2015. SCAN disagreed with their findings and after review the OIG revised the number of un-validated HCCs and changed the recommended refund amount due by SCAN.  The link to the report is found: Medicare Advantage Compliance Audit of Diagnosis Codes That SCAN Health Plan (Contract H5425) Submitted to CMS (hhs.gov) https://oig.hhs.gov/oas/reports/region7/71701169.asp Disclaimer: This guidance is to be used for an easy reference; the...