CMS’s Plan to Audit All MA Plans Brings More Bad News for UnitedHealth, Humana
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May 30, 2025
Amid a flurry of CMS announcements about health care price transparency and Medicaid issues, the agency on May 21 unveiled a bold plan to collect Medicare Advantage overpayments through the expansion of Risk Adjustment Data Validation (RADV) audits. Industry analysts say the news could be especially bad for Humana Inc. and UnitedHealth Group, although it remains to be seen whether CMS will be able to meet its lofty goals for the pace and scope of the planned audits.
In a process initiated more than a decade ago, CMS conducts RADV audits of a select group of MA contracts to verify that diagnoses submitted by MAOs for risk adjustment purposes are accurate and supported by medical records. The agency this year selected 60 MA organizations for RADV audits of payments issued in 2018. That is also the first payment year for which CMS will apply an extrapolation methodology, which has been challenged in a lawsuit filed by Humana and is expected to significantly boost the recoveries sought by CMS.
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