When CMS proposed expanding the risk adjustment audit program in 2015, it was looking to cover all Medicare Advantage (MA) Plans, annually. CMS wanted one of two conditions:
- Condition-Specific
- Comprehensive Audits
CMS wanted one of the two implemented due to the fact that the powers at be then, strongly believed that the diagnosis data was fraught with epic upcoding mistakes which were being submitted by all the MAorganizations. This was a concern for CMS as they were concerned that there would be significant misallocation of resources. Some MA Plans might be overpaid on their members and some might be underpaid on their members.
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