Becker's Healthcare February 15, 2023
In January, CMS said it will implement stricter auditing practices around Medicare Advantage plans, but payers and policy experts say they have a lot of questions about the next steps forward.
The new risk-adjustment data validation audit rule is expected to leave commercial payers collectively on the hook for up to $4.7 billion in repayments to the federal government over the next decade. The final rule will only apply to contracts dated from payment year 2018 and up.
Nearly every major insurance company has been accused of or settled allegations of MA fraud in recent years, which the industry disputes. Payers are accused of exploiting the program through “upcoding” schemes that make patients appear sicker on medical records than...
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