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CMS proposes tweaking ACA risk-adjustment audit methodology
Modern Healthcare May 29, 2020
The CMS on Friday issued a proposed rule to tweak the way it audits the Affordable Care Act’s risk-adjustment program, which is meant to reduce incentives for health insurers to cherry-pick the healthiest, low-cost plan members.
The agency proposed making technical changes to how it audits the accuracy of data submitted by payers under the risk-adjustment program, which it said would strengthen the program’s integrity.
Risk adjustment shuffles money from plans that enroll relatively healthy members to plans with sicker, riskier patients. Payments and charges under the program are calculated based on patient “risk scores,” which are determined by demographic information and health conditions. Insurers are audited to ensure they submit accurate data.
The changes that CMS wants to make...
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