HCC Blog by Caridad

The Office of Inspector General (OIG) released a publication entitled,  Medicare Advantage Industry Segment-Specific Compliance Program Guidance, February 2026. It describes risk areas in the Medicare Advantage Organization (MAO) program, recommendations to mitigate those risks and information to consider in compliance programs.  For risk adjustment, take a look at Section II. Compliance Risk Areas and Recommendations for Mitigation, section C. Risk Adjustment OIG has examined MAOs reporting diagnoses based solely on chart reviews or health risk assessments (HRAs) and providing no other records in the encounter data that enrollees received services for the diagnoses. "These resources are not one-size-fits-all, comprehensive, or inclusive of all compliance considerations or risks. They are not binding on any individual or entity. Of note, OIG uses the word “should” in the Medicare Advantage ICPG and GCPG to present voluntary, nonbinding guidance. This means that the docume...

This is the detailed information on Risk Adjustment in Medicare Advantage Plans, a 201 page document.  Section 2 is a "PRIMER ON RISK ADJUSTMENT AND THE CMS-HCC MODEL" https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/RTC-Dec2018.pdf DECEMBER 2018 Accessed April 17 2020 Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to take the place of either the written law or regulations.  The information presented herein is for general informational purposes only and is accurate as of the date of publication.