CMS Finalizes Risk Validation Audit Rules For Medicare Advantage To Reclaim $4.7 Billion In Improper Overpayments For 2011 To 2022 Owed By Insurers

On February 1, 2023, the Centers for Medicare & Medicaid Services (CMS) finalized rules for conducting Medicare Advantage Risk Adjustment Data Validation (RADV) audits and clarified how it will calculate the amounts plans owe. Insurers in Medicare Advantage get paid more for enrolling sicker health care consumers, and the audits are meant to assure payment accuracy by comparing payments against consumers' medical records. Contract-level RADV audits are the main corrective action for overpayments made to Medicare Advantage organizations (MAOs) when there is a lack of documentation in the medical record to support the diagnoses reported for risk adjustment. The . . .