MA Organizations Can Expect Biden Administration to Revisit RADV Rule

Feb 05
Feb 05, 2021

Notably missing from the Trump administration’s late-term rulemaking blitz was a longstanding proposal regarding Risk Adjustment Data Validation (RADV) audits, but industry observers say it will likely be revisited by the Biden administration.

CMS has for the last decade been conducting contract-level RADV audits to verify the accuracy of payments made to MA organizations and recover improper payments, and in 2012 said it planned to adopt a “fee-for-service adjuster” to account for any impact from inaccurate diagnosis codes in FFS data that are used to calibrate the MA risk adjustment model. But the agency in a November 2018 proposed rule (83 Fed. Reg. 54982, Nov. 1, 2018) said its plans to recoup improper payments starting with payment year 2020 would not involve an FFS adjuster and that it may apply this extrapolation methodology when finalizing audits dating back to payment year 2011 (RMA 11/1/18, p. 1).
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Lauren Flynn Kelly

Lauren has been covering health business issues since the early 2000s and specializes in in-depth reporting on Medicare Advantage, managed Medicaid and Medicare Part D. She also possesses a deep understanding of the complex world of pharmacy benefit management, having written AIS Health’s Radar on Drug Benefits from 2004 to 2005 and again from 2011 to 2016. In addition to her role as managing editor of Radar on Medicare Advantage, she oversees AIS Health’s publications and manages the health editorial staff. She graduated from Vassar College with a B.A. in English.