Risk Adjustment Data Validation of Payments Made to PacifiCare of California for Calendar Year 2007

This report released on November 20, 2012, the federal Department of Health and Human Services (HHS ) Office of Inspector General (OIG) is a performance audit of PacifiCare, a Medicare Advantage program contractor. For this audit, the OIG sought to determine whether the diagnoses that PacifiCare submitted to Medicare in the risk score calculation complied with federal requirements. Medicare uses the risk score calculation to adjust the monthly capitated rate for the next payment period. For the audit, the OIG selected a random sample of 100 beneficiaries, and then extrapolated the findings to all beneficiaries covered by PacifiCare. Within the random . . .