Skip to main content

Masthead

  • Member Login
  • Join Mass Senior Care
  • Contact
  • Search
    Advanced Search

Main navigation

  • About Us
    • Learn More About MSCA
    • Board of Directors
    • Staff Directory
    • Newsroom
      • Mass Senior Care Press Releases
      • Mass Senior Care in the News
  • Education & Events
    • 2023 Events
    • Webinars / Education Programs
    • Education and Seminar Policies and Procedures
  • Member Resources
    • E-News Updates
      • Past Newsletters
    • Preferred Vendors
    • Coronavirus Information and Resources
    • COVID-19 Vaccine
    • Quality & Wellness Initiatives
      • Fight the Flu Campaign
      • The Massachusetts Healthcare Safety and Quality Consortium
      • Sepsis Smart
      • Care Transitions
      • Culture Change
      • End of Life Care
      • Falls Prevention
      • Reducing Off-Label Use of Antipsychotics
    • Labor and Workforce
    • Regulatory
    • Reimbursement
      • Nursing Facility Census
    • Policy Committees
    • Other Resources
      • MassMAP (LTC Mutual Aid Plan)
      • Activities Professional (MassCAP)
      • AHCA/NCAL Bookstore
  • Advocacy
    • Advocacy Center
    • Legislative Priorities
    • Respect & Protect Nursing Home Caregiver Wages
  • Careers
    • Career Opportunities
    • RCA Training Course
    • Care For The Aging
    • Find a Job
    • Members Post a Job
  • For Consumers
    • Care Options
    • Find A Facility
    • How to Choose a Facility
    • Health Care Planning
    • Our Senior Care
  • Foundation

CMS Issues Medicare Advantage Risk Adjustment Data Validation Final Rule

Breadcrumb

  • Home
  • Member Resources
  • E-News Updates
  • CMS Issues Medicare Advantage Risk Adjustment Data Validation Final Rule
February 6, 2023
Thumbnail

In a final rule released on January 30th, the Centers for Medicare & Medicaid Services (CMS) finalized technical details regarding the Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) program that CMS uses to recover improper risk adjustment payments made to Medicare Advantage (MA) plans. The RADV final rule is intended to help CMS to protect the MA program by addressing instances where Medicare paid Medicare Advantage Organizations (MAOs) more than they otherwise should have received because the medical diagnoses submitted for risk adjustment payment were not supported in the beneficiary’s medical record. Specifically, this final rule codifies in regulation that, as part of the RADV audit methodology, CMS will extrapolate RADV audit findings beginning with payment year (PY) 2018.

As required by law, CMS’ payments to MAOs are adjusted based on the health status of enrollees, as determined through medical diagnoses reported by MAOs. Studies and audits done separately by CMS and the HHS Office of Inspector General (OIG) have shown that Medicare Advantage enrollees’ medical records do not always support the diagnoses reported by MAOs, which leads to billions of dollars in overpayments to plans and increased costs to the Medicare program as well as taxpayers. Despite this, no risk adjustment overpayments have been collected from MAOs since Payment Year (PY) 2007. 

The RADV final rule can be accessed at the Federal Register here: https://www.federalregister.gov/public-inspection/2023-01942/medicare-and-medicaid-programs-policy-and-technical-changes-to-the-medicare-advantage-medicare

View the fact sheet on the final rule here: https://www.cms.gov/newsroom/fact-sheets/medicare-advantage-risk-adjustment-data-validation-final-rule-cms-4185-f2-fact-sheet.

Upcoming Education & Events

calendar icon
Mar
29

March 29 at 10:30 am

The RCA to CNA Pipeline: Leveraging Rapid Upward Mobility

Apr
4

April 4 at 2:00 pm

Audits & Investigations: What to do when the Government comes “knocking”

View Entire Calendar

Find a Facility

Recent News

newspaper icon
March 24, 2023
Register Now for Important Webinars – New RCA to CNA Pipeline Workshops Next Wednesday, March 29th
March 24, 2023
REMINDER: Cases of C. auris on the Rise in Healthcare Facilities
View All Recent News

Find a Preferred Vendor

msca logo

Footer menu

  • Contact
  • Privacy Policy
  • Terms & Conditions

State Affiliate Of