CMS finalizes RADV rules for Medicare Advantage plans

Medicare Advantage providers will handle diagnostic coding errors from 2018 in accordance with a final rule issued Monday by the Centers for Medicare and Medicaid Services.

The Medicare Risk Adjusted Data Validation Regulation, or RADV, took five years to complete after a draft version was published in 2018 and drew fierce opposition from the health insurance industry.

“What we’re doing here with the RADV final rule is to give Medicare Advantage plans clarity. We are giving them a long-term vision and approach to RADV audits and that will allow us to keep the MA [organizations] responsible for receiving payments they are not entitled to,” CMS Deputy Administrator and Program Integrity Center Director Dara Corrigan told reporters during a press conference Monday.

CMS expects to recover $479 million from the 2018 plan year and expects to recover $4.7 billion between 2023 and 2032.

In addition to planning to recover amounts that CMS determines should not be paid, the agency will stop applying the service charge adjuster to its audit findings, which was used to ensure Medicare and Medicare Advantage payments are actually equivalent.

The CMS’ approach to these audits will be significantly different from the previous policy. Instead of reviewing insurance company claims forms to determine if they are being paid correctly, the agency extrapolates error rates from those assessments and applies them to the entire plan. plan. The proposed rule would go into effect in 2011, but the CMS would instead limit its scope from 2018 onwards.

Executives from Humana, CVS Health’s Aetna and Centene expressed concern about the proposed rule at the JP Morgan Health Conference this month. Several companies said they would sue CMS if the service fee adjustment was not included in the final rule.

“It’s hard to predict what will happen if there’s litigation, and we certainly don’t want to start speculating about litigation, but we believe we’ve come up with a rule that not only balances, measures and fairness, but also as a rule ready for due process”. time,” Health and Human Services Secretary Xavier Becerra said at a news conference.

AHIP, the largest health insurance trade association, criticized the last rule. “Our position has remained unchanged: This rule is illegal and seriously flawed, and should have been withdrawn rather than perfected,” said AHIP President and CEO, Matt Eyles. , said in a press release. those who need the most care. Furthermore, the rule would raise prices for seniors and taxpayers, reduce benefits for those choosing an MA, and offer fewer program options in the future.”

The Union of Public Health Plans, which represents nonprofit health insurance companies, also rejected the rule. President and CEO Ceci Connolly said in a statement: “This rule comes with enormous costs and does not target the most serious diagnostic cryptographic breaches. disrupts subscriber care and does not address program integrity, according to the organization.

The Blue Cross Blue Shield Association gave a measured response. “We support policies and programs that deliver better patient outcomes and affordable, high-quality care. We are currently reviewing the new risk-adjusted Data Validation provision and will continue to work with the authorities to improve [Medicare Advantage] and its risk-adjusted program to deliver higher quality, more affordable, and fairer health care to millions of beneficiaries,” the organization said in a statement.

CMS pays private Medicare providers based on recorded risk scores that reflect the health of their members. Regulators are concerned that this creates a financial incentive for insurers and providers to tokenize and exaggerate patient conditions to generate additional reimbursements.

Medicare Advantage insurers generated an estimated $17 billion through overpayments last year, according to the Medicare Payments Advisory Committee, which makes policy recommendations to Congress.

Medicare Advantage providers are under increasing pressure to own overpayments. In June, the Supreme Court declined to hear UnitedHealth Group’s claim against a rule that holds Medicare Advantage insurers liable for False Claims Act lawsuits when they do not reimbursement of overpayments.

Lindsey Fetzer, an attorney at Bass, Berry & Sims specializing in Medicare Advantage, said CMS has provided a middle ground by not expanding extrapolation terms since 2018, but removing the fee modifier. cases that are likely to cause lawsuits.

“In terms of an immediate analysis of what the financial impact looks like, that is better than some would expect, but I would still say the potential impact of allowing extrapolation will change,” Fetzer said. fundamentally change the way plans can work,” Fetzer said.

Correction: A previous version of this article misrepresented the Centers for Medicare and Medicaid Services’ forecast of how much the Medicare Risk Adjusted Data Validation regulation would pay the government.


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