CMS Issues Long-Awaiting Medicare Advantage RADV Final Rule

Lexology February 1, 2023
Sheppard Mullin Richter & Hampton LLP

On January 30, 2023, the Centers for Medicare & Medicaid Services (“CMS”) released the long-delayed final rule on risk adjustment data validation (“RADV”) audits of Medicare Advantage (“MA”) organizations (the “Final Rule”). CMS promotes the Final Rule as improving program integrity and payment accuracy as well as transparency and certainty. One thing that is certain, CMS can expect further challenges to its RADV audit methodology.

The Final Rule implements the following changes:

• CMS will extrapolate RADV audit findings beginning with payment year (“PY”) 2018 and will not extrapolate RADV audit findings for PYs 2011 through 2017. This applies to both CMS RADV audits as well as Department of Health and Human Services Office of Inspector General (“OIG”) RADV audits.
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