CMS Issues Final Rule for MA Risk Adjustment Audits

Posted February 1, 2023

Hospice providers rely on Medicare Advantage (MA) reimbursement to support palliative care, PACE and social determinants programs, among others.  Last week, CMS laid out its policy for validating MA plans’ risk adjustment data, which the agency uses to calculate capitation rates. Through the MA Risk Adjustment Data Validation (RADV) program, CMS will be auditing beneficiary medical records to identify potential improper payments.

RADV is designed to ensure that a beneficiary’s diagnoses are supported by their medical documentation.

“CMS is committed to protecting people with Medicare and being a responsible steward of taxpayer dollars,” said CMS Administrator Chiquita Brooks-LaSure. “By establishing our approach to RADV audits through this regulation, we are protecting access to Medicare both now and for future generations. We have considered significant stakeholder feedback and developed a balanced approach to ensure appropriate oversight of the Medicare Advantage program that aligns with our oversight of Traditional Medicare.”

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