Extrapolation Has Arrived: CMS Finalizes Medicare Advantage Risk Adjustment Rule

Lexology February 16, 2023
Ropes & Gray LLP

Introduction

On February 1, 2023, the Centers for Medicare & Medicaid Services (“CMS”) published a long-awaited and controversial final rule that implements technical changes to the Medicare Advantage (“MA”) contract-level Risk Adjustment Data Validation (“RADV”) program (the “RADV Final Rule”).¹

Following years of proposed rules, public comment, and litigation, the RADV Final Rule contains three key takeaways that will impact MA stakeholders:

1. It implements extrapolation of RADV audit findings commencing payment year (“PY”) 2018;²
2. It rejects a Fee-For-Service (“FFS”) adjuster for MA risk adjustment that would have limited the financial impact of the RADV Final Rule for Medicare Advantage Organizations (“MAOs”); and
3. It clarifies that MA overpayment self-reporting and repayment requirements for MAOs will be forthcoming from CMS.

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