CMS finalizes RADV rule, leave MA plans on the hook for billions

January 30, 2023


Medicare Advantage carriers will be on the hook for errors made in diagnostic coding reaching back to 2018 under a final rule the Centers for Medicare and Medicaid Services issued Monday.

The Medicare Risk Adjustment Data Validation, or RADV, regulation took five years to complete after its draft version published in 2018 and attracted vehement opposition from the health insurance industry.

“What we’re doing here with the RADV final rule is to provide to the Medicare Advantage plans clarity. We’re providing to them our long-term vision and approach to RADV audits and it will allow us to hold MA [organizations] accountable for receiving payments to which they are not entitled,” CMS Center for Program Integrity director Dara Corrigan told reporters during a briefing Monday.

CMS expects to recover $479 million from payment year 2018, and projects it will recoup more than $4 billion over the 10-year period beginning that year, Corrigan said.

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