OIG’s Medicare Advantage Priorities: What Plans Need to Know

At the recent RISE Medicare Advantage Member Accounting and Reconciliation Summit, Ann Maxwell, Deputy Inspector General for Evaluation and Inspections at the Department of Health and Human Services (HHS) Office of Inspector General (OIG), shared key insights into the agency’s current priorities—and issued a clear message to Medicare Advantage (MA) plans: compliance risks are growing, and proactive steps are needed now.

From increased oversight and rising costs to the growing use of AI in risk adjustment, Maxwell’s keynote highlighted where MA plans are vulnerable and what actions can help safeguard program integrity.

The Compliance Landscape Is Shifting

Maxwell opened by framing today’s regulatory environment. MA plans are reimbursed at approximately 122% of traditional Medicare costs and are facing intensified scrutiny. CMS is ramping up Risk Adjustment Data Validation (RADV) audits to ensure submitted diagnosis codes are supported by clinical documentation. At the same time, HHS Secretary Robert F. Kennedy Jr is prioritizing holistic, preventative care and better long-term outcomes.

Against this backdrop, Maxwell posed critical questions: How can MA remain sustainable? How do plans ensure compliance while still delivering high-quality outcomes? And, most importantly, how do we preserve trust from members, providers, and taxpayers?

OIG’s Top Oversight Goals

Maxwell outlined three focus areas driving OIG’s oversight:

Access to Care
With over 30 million members, MA must ensure timely and appropriate services. OIG has identified patterns where care or provider payments are wrongly denied—raising red flags about whether plans are serving their enrollees effectively.

Financial Oversight
The federal government spent $462 billion on MA in 2024. Audits continue to reveal billions in overpayments—often from diagnosis codes not supported in the medical record. Ensuring the accuracy of both risk-adjusted and capitated payments remains a central concern.

Data Accuracy
“AI is only as good as the data it’s fed,” Maxwell warned. Plans leveraging AI must ensure data quality and completeness. Poor data not only undermines analytics—it wastes resources and misguides oversight efforts.

OIG's Risk Adjustment Red Flags

Maxwell emphasized that while risk adjustment is essential to promoting health equity, it also creates incentives to inflate risk scores. “It’s the difference between coding for care and coding for cash flow,” she said. The OIG is closely monitoring several high-risk practices:

Diagnosis Codes
OIG audits found that up to 70% of submitted diagnosis codes lacked supporting medical documentation. Often, high-risk codes (e.g., acute stroke, cancer, embolism) were submitted without evidence of corresponding treatment. This isn’t just an isolated error—it’s a systemic issue, Maxwell warned.

Chart Reviews
MA plans are permitted to use retrospective chart reviews to identify or update diagnoses. However, OIG’s analysis showed that 99% of chart reviews resulted in adding codes, with almost no deletions. Even more concerning, added diagnoses often had no evidence of care. In one case, a $229,000 payment was triggered by a chart review with no follow-up care documented.

OIG is now investigating “unlinked chart reviews”—where diagnosis codes added via chart review lack a clear, date-specific service record.

Health Risk Assessments (HRAs)
In-home HRAs generated $7.5 billion in risk adjustment payments in 2023—yet often, there’s no care documented beyond the assessment itself. Maxwell questioned why members with serious diagnoses are not receiving follow-up treatment if these assessments are accurate.

She applauded steps taken by UnitedHealthcare and Humana to limit risk payments when diagnoses appear only on HRAs, calling their reforms “a promising sign of industry accountability.”

Provider Fraud
Beyond coding practices, OIG remains concerned about fraud by providers and suppliers within MA. These schemes harm plans and taxpayers alike. Maxwell emphasized the need for collaboration: “We want to help you stop that.”

Four Compliance Imperatives for MA Plans

Maxwell concluded with four concrete steps that MA organizations should take now to strengthen compliance and reduce audit risk:

Invest in Internal Compliance Infrastructure
Plans should proactively conduct internal audits and risk assessments—especially in areas like chart reviews and HRAs. Maxwell recommended reviewing the OIG’s 2023 General Compliance Program Guidance to ensure robust policies are in place.

Audit and Validate Your Data
Incomplete records can give the impression that members aren’t receiving care. Plans should audit high-risk diagnosis codes using the OIG’s downloadable toolkit, built on a decade of audit experience. It offers practical methods to validate diagnoses before external auditors intervene.

Ensure Follow-Up After HRAs
Plans must ensure that diagnoses flagged through HRAs—especially in-home assessments—are tied to actual care delivery. Maxwell urged organizations to follow the example set by Humana and UnitedHealthcare in setting stricter documentation and follow-up standards.

Engage with the OIG
Maxwell stressed the importance of communication and collaboration. “We want what you want,” she said. “A Medicare Advantage program that delivers meaningful care to patients and functions well. So let’s do that together.”

Final Thoughts

Ann Maxwell’s keynote served as both a warning and a call to action for Medicare Advantage plans. As oversight intensifies, MA organizations must recommit to data accuracy, ethical coding, and meaningful care delivery. Those that do will not only avoid costly audits—they’ll help preserve the long-term sustainability and trust at the heart of the Medicare Advantage program.

At ForeSee Medical, we understand the compliance and operational challenges highlighted by the OIG—and we’ve built our AI-powered risk adjustment platform to help you meet them head-on. ForeSee’s point-of-care platform leverages advanced AI—specifically natural language processing and machine learning—to identify and surface potential HCC-related conditions from clinical documentation. InstaVu®, our proprietary risk adjustment interface, links HCC suspects to their source document, enabling clinicians to efficiently review and validate the underlying evidence. Providers retain full clinical autonomy in determining whether to confirm or dismiss suspects and all documentation is preserved to support diagnostic decision-making and audit readiness.

In an era of heightened scrutiny, trust your risk adjustment strategy to a platform built for precision, compliance, and results.

Blog by: The ForeSee Medical Team