CMS set to expand Medicare Advantage audits 

WASHINGTON – CMS has published a final rule in the Federal Register that codifies in regulation that, as part of the Medicare Advantage Risk Adjustment Data Validation (RADV) program, the agency will extrapolate audit findings beginning with payment year 2018. 

“Protecting Medicare is one of my highest responsibilities as secretary, and this commonsense rule is a critical accountability measure that strengthens the Medicare Advantage program,” said Xavier Becerra, secretary of the Department of Health and Human Services. “CMS has a responsibility to recover overpayments across all of its programs, and improper payments made to Medicare Advantage plans are no exception. For years, federal watchdogs and outside experts have identified the Medicare Advantage program as one of the top management and performance challenges facing HHS, and today we are taking long overdue steps to conduct audits and recoup funds. These steps will make Medicare and the Medicare Advantage program stronger.” 

Studies and audits done separately by CMS and the HHS Office of Inspector General (OIG) have shown that Medicare Advantage enrollee medical records do not always support the diagnoses reported by Medicare Advantage organizations, which leads to billions of dollars in overpayments to plans and increased costs to the Medicare program, as well as taxpayers. Despite this, CMS hasn’t collected risk adjustment overpayments from these organizations since payment year 2007. 

The RADV final rule reflects CMS’s consideration of extensive public comments and robust stakeholder engagement after the release of the notice of proposed rulemaking in 2018. 

The RADV final rule can be accessed at the Federal Register here. 

View the fact sheet on the final rule here.

• Read about how a recent OIG report ‘exposes’ Medicare Advantage.