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).