Three Medicare Advantage risks. One clear message from OIG: your compliance program needs to be ready.
With the release of the Medicare Advantage ICPG, compliance expectations are more defined—and more enforceable—than ever before. In Part 1 of this series, we take a focused look at three of the most critical risk areas outlined by OIG:
1. Risk Adjustment
Improper diagnosis coding continues to drive enforcement activity. From unsupported chart reviews to in-home assessments that don’t reflect actual care, OIG is closely monitoring how risk scores are built—and whether they are defensible.
2. Submission of Accurate Claims
The connection to the False Claims Act is explicit. When organizations submit inaccurate or unsupported data to CMS, the risk isn’t just operational—it’s legal.
3. Quality of Care
Reimbursement is increasingly tied to outcomes. That means the integrity of quality data, star ratings, and patient care reporting is under scrutiny.