Improving Payment Accuracy in Medicare Part C

The Payment Integrity Information Act of 2019 (PIIA) requires the Centers for Medicare & Medicaid Services (CMS) to estimate and report the annual improper payment rate for Medicare Part C. Beyond measuring overall payment accuracy, CMS looks to understand the underlying causes of payment error so that it can strengthen program oversight and reduce future improper payments. Identifying those drivers requires a deep understanding of Medicare Part C payment policy, risk adjustment models, encounter data, medical record review findings, and associated compliance and program integrity risks. The complexity of these interconnected factors can make it challenging to determine which issues contribute most significantly to payment error and where corrective efforts may have the greatest impact.

Emendata supports the process by identifying and evaluating potential drivers of improper payment in Medicare Part C. Our analyses connect payment error findings to the policies, requirements, and incentive structures that shape program behavior. In some cases, we begin with known compliance or program integrity risks and assess their contribution to payment error; in others, we start with patterns observed in the data and trace them back to their underlying causes. This approach helps CMS identify issues that can be addressed through targeted corrective actions and program improvements.

By connecting payment error to its underlying causes, these analyses have helped transform complex findings into actionable recommendations for CMS, ranging from enhanced guidance for Medicare Part C plans to targeted oversight and enforcement strategies. These insights help strengthen CMS’s stewardship of a program that represents hundreds of billions of dollars in annual expenditures.