The Centers for Medicare and Medicaid Services (CMS) announced May 21 that it would begin conducting annual Risk Adjustment Data Validation (RADV) audits on all eligible Medicare Advantage plans and invest additional resources to expedite completion of audits of payment years 2018-2024.

The purpose of RADV audits is to confirm that the diagnoses that are used for determining MA plan payments are supported by patients’ medical records. This practice is sometimes referred to as “upcoding.” The Medicare Payment Advisory Commission has reported to Congress that they calculate that plans are paid as much as 22% more than Medicare fee-for-service (FFS) due to MA plans upcoding.

CMS Administrator Dr. Mehmet Oz stressed that, “While the administration values the work that Medicare Advantage plans do, it is time CMS faithfully executes its duty to audit these plans and ensure they are billing the government accurately for the coverage they provide to Medicare patients.”

CMS will use technology and add nearly 2,000 medical coders to manually verify items flagged by the new technologies used.  These efforts are believed to be able to increase the number of health plan audits from 35 records per year to 200.

LeadingAge has been supportive of the Administration and Congress correcting these overpayments to MA plans to preserve the solvency of the Medicare Trust Fund. We would also like to see CMS make a similar investment in regulatory compliance audits of MA plans to ensure they are following prior authorization rules and not erroneously delaying or denying care.