CMS Finalizes RADV Rule for Medicare Advantage Plans

Medicare Advantage carriers will be held liable for diagnostic coding errors starting in 2018 under the final rule released Monday by the Centers for Medicare and Medicaid Services.

The Medicare Risk Adjustment Data Review Ordinance, or RADV, took five years to complete after a draft version was published in 2018 and met with fierce opposition from the health insurance industry.

“What we’re doing here with the final RADV rule is clearing up Medicare Advantage plans. We provide them with our long-term vision and approach to RADV audits and this will allow us to conduct the MA [organizations] responsible for receiving payments they are not entitled to,” Dara Corrigan, director of the CMS Center for Program Integrity, told reporters at a briefing on Monday.

According to Corrigan, CMS expects to recover $479 million for the 2018 billing year and forecast to recover more than $4 billion over a 10-year period starting this year.

In addition to scheduling the return of funds that CMS believes should not have been paid, the agency will no longer apply the fee-for-service evaluator to the audit results used to secure Medicare and Medicare Advantage fee-for-service payments. were actuarially equivalent.

CVS Health’s Humana, Aetna and Centene executives raised concerns about the proposed rule at a JP Morgan Healthcare conference this month. Several plans state that they will sue CMS if the appraiser is not included in the final rule.

Michael Bagel, deputy vice president of public policy at the Alliance of Community Health Plans, said in an interview before the final rule was released that the nonprofit insurers trade group was concerned about the proposed methodology for determining when insurers would have to pay the government. , And how many.

CMS pays private Medicare providers based on documented risk scores that reflect the health of their members. Regulators are concerned that this creates a financial incentive for insurers and healthcare providers to raise codes and exaggerate patient conditions for more reimbursements.

According to the Medicare Payments Advisory Commission, which advises Congress on policy, Medicare Advantage insurers made about $17 billion in overpayments last year.