Medicare Advantage plans do not need a new doctor visit to raise a patient's risk score. A retrospective chart review lets the plan or a vendor comb an enrollee's medical record for a diagnosis the treating clinician never submitted, then send it to CMS for a higher risk-adjusted payment. The same review can show a diagnosis already on file is unsupported, but investigators keep finding plans that run the practice one way only, adding diagnoses while leaving the unsupported ones alone. On September 30, 2026, the Department of Justice announced a $22.5 million settlement with Independence Blue Cross covering payment years 2017 through 2021.
How a Retrospective Chart Review Program Works
A Medicare Advantage organization is paid more for enrollees CMS expects to cost more to treat, based on the diagnosis codes it submits, so plans are allowed to look for diagnoses after the fact. A chart review sends coders or nurse reviewers through medical records a provider already wrote, looking for a diagnosis the chart supports but a claim never reported. Some plans route the same question through the provider's electronic medical record (EMR) system, prompting a physician to confirm or add a diagnosis. The Medicare Advantage Industry Segment-Specific Compliance Program Guidance the HHS Office of Inspector General issued in November 2024 lists both practices among the conduct federal investigations have found fraudulent or abusive when the added diagnosis was unsupported or did not reflect the patient's care.
The Add-Only Pattern Investigators Keep Finding
According to the government, Independence Blue Cross used nurse reviewers to examine medical records for risk-adjusting conditions the records supported, then submitted those diagnosis codes to CMS. The same reviews turned up diagnosis codes IBX had already submitted that the records did not support, and rather than withdraw them and repay the overpayment, the government alleges IBX kept them on file and certified in writing that its data was accurate and truthful. An October 2024 OIG report found a related pattern: diagnoses reported only on health risk assessments and the chart reviews linked to them, with no other service record in a beneficiary's file, produced an estimated $7.5 billion in Medicare Advantage risk-adjusted payments for 2023; in-home health risk assessments and the chart reviews linked to them accounted for almost two-thirds of that total, and just 20 MA companies accounted for 80 percent of it.
A chart review that only adds diagnoses, and never removes the ones the same review shows are unsupported, is the pattern the Department of Justice has alleged violates the False Claims Act and the HHS Office of Inspector General lists among potentially fraudulent and abusive conduct.
Why an Unsupported Diagnosis Creates Exposure for the Provider, Not Just the Plan
CMS requires a risk-adjusting diagnosis code to come from a face-to-face visit documented in the medical record. OIG's November 2024 guidance names "providers submitting diagnoses that were not supported by the enrollees' medical records to inflate the payments MAOs made to the providers under risk-sharing or other arrangements" as conduct federal investigations have already found. A physician who signs a chart review vendor's attestation for a diagnosis the chart does not support takes on that exposure personally, and the signature can leave the provider owing a recoupment on top of whatever the plan owes CMS.
What a Provider Should Do Before Signing a Chart Review Attestation
A chart review request or an EMR-generated prompt is not proof of anything by itself. Before signing, confirm the diagnosis was actually made while treating the patient, supported by documentation already in the chart, not merely suggested by the vendor's query. Ask the vendor where the diagnosis is documented, keep a copy of whatever gets signed, and involve compliance staff or counsel before an addendum changes the patient's coded clinical picture.
Why Early Legal Counsel Is Critical
It is critical that physicians and Medicare Advantage organizations promptly retain experienced healthcare defense counsel upon receiving a chart review attestation request, a RADV audit notice, or any related CMS or OIG inquiry tied to risk-adjustment diagnoses. Early legal intervention can protect the provider's rights, ensure an accurate response, avoid inadvertent admissions, preserve relevant defenses, and allow counsel to communicate with the plan, CMS, or investigators on the provider's behalf. Delaying legal representation can significantly affect the outcome of a matter and expose the provider to False Claims Act liability that careful handling could have avoided.
How Health Law Alliance Can Help
Health Law Alliance represents physicians, physician groups, and healthcare companies through chart review requests, risk-adjustment inquiries, and the False Claims Act exposure that follows an unsupported diagnosis.
Health Law Alliance's attorneys have overseen 2,000+ audits and handled 5,000+ matters, with 25+ years of experience.
If a Medicare Advantage plan or its chart review vendor has asked a physician or practice to sign off on an added diagnosis, contact Health Law Alliance's Medicare audit defense team for a free, confidential consultation before signing.
