KHN Report Underscores Looming Issue of Extrapolation, FFS Errors in RADV Audits

After settling a three-year Freedom of Information Act (FOIA) lawsuit, Kaiser Health News (KHN) last month finally made public the results of multiple CMS audits of Medicare Advantage plans — which showed the federal government intends to collect an estimated $12 million for overpayments identified over a three-year period. KHN said it filed the lawsuit against CMS in September 2019, after the agency failed to respond to a FOIA request for the audits pertaining to care delivered between 2011 and 2013.

Those years represent the latest Risk Adjustment Data Validation (RADV) audits to be completed, referring to contract-level audits conducted by CMS to verify the accuracy of payments made to MA organizations and recover improper payments. Industry experts say the results obtained by KHN may not be representative of insurer practices today, and that they highlight the overarching question of whether the audit methodology that CMS may soon finalize aligns with the current payment and bidding system that’s in place for MA.

© 2024 MMIT
Lauren Flynn Kelly

Lauren Flynn Kelly Managing Editor, Radar on Medicare Advantage

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.

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