HIT Consultant September 27, 2024
Risk adjustment requires constant attention to ensure accurate coding, timely regulatory compliance, and streamlined communications across the payer-provider continuum. Increasingly rigorous oversight from the Centers for Medicare & Medicaid Services (CMS) and Office of the Inspector General (OIG) are calling for better diligence, planning and administrative oversight for effective risk adjustment.
The January 2023 rule from CMS, which struck the fee-for-service adjuster from risk adjustment data validation (RADV) audits, has also increased concern among Medicare Advantage (MA) plans. Put into effect with the goal of recouping unjustified costs, CMS estimates a recovery of more than $4.7 billion in overpayments to MA plans with this new audit methodology over the next ten years. One major payer recently filed a lawsuit...
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