www.cms.gov Open in urlscan Pro
2a02:26f0:3500:590::28a  Public Scan

Form analysis
1 forms found in the DOM

GET /newsroom/search

<form action="/newsroom/search" method="get" id="views-exposed-form-newsroom-of-acquia-search-page" accept-charset="UTF-8">
  <div class="search-box-container">
    <main role="main">
      <div class="clearfix">
        <div class="search-dropdown-container">
          <label class="ds-u-visibility--screen-reader" for="select-search-language">Select search language:</label>
          <div class="search-language desktop"><!-- TODO: hide this in mobile view -->
            <select id="select-search-language">
              <option value="en" class="full-language">English</option>
              <option value="es" class="full-language">Español</option>
            </select>
          </div>
          <div class="js-form-item form-item js-form-type-search-api-autocomplete form-type-search-api-autocomplete js-form-item-search form-item-search">
            <label for="edit-search">Search newsroom articles</label>
            <input placeholder="Search newsroom articles" aria-label="Search newsroom articles" aria-expanded="false" role="combobox" type="text" data-drupal-selector="edit-search" data-search-api-autocomplete-search="newsroom_of_acquia_search"
              class="form-autocomplete form-text ui-autocomplete-input" data-autocomplete-path="/search_api_autocomplete/newsroom_of_acquia_search?display=page&amp;&amp;filter=search" id="edit-search" name="search" value="" size="30" maxlength="128"
              data-once="autocomplete search-api-autocomplete" autocomplete="off">
          </div>
          <div class="js-form-item form-item js-form-type-select form-type-select js-form-item-search-api-language form-item-search-api-language form-no-label">
            <select data-drupal-selector="edit-search-api-language" id="edit-search-api-language" name="search_api_language" class="form-select" title="Language selector">
              <option value="All">- Any -</option>
              <option value="***LANGUAGE_site_default***">Site's default language (English)</option>
              <option value="***LANGUAGE_language_interface***">Interface text language selected for page</option>
              <option value="en" selected="selected">English</option>
              <option value="es">Spanish</option>
              <option value="und">Not specified</option>
              <option value="zxx">Not applicable</option>
            </select>
          </div>
          <fieldset data-drupal-selector="edit-field-date-wrapper" id="edit-field-date-wrapper" class="js-form-item form-item js-form-wrapper form-wrapper">
            <legend>
              <span class="fieldset-legend">Date</span>
            </legend>
            <div class="fieldset-wrapper">
              <div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-field-date-min form-item-field-date-min">
                <label for="edit-field-date-min">Min</label>
                <input data-drupal-selector="edit-field-date-min" type="text" id="edit-field-date-min" name="field_date[min]" value="" size="30" maxlength="128" class="form-text">
              </div>
              <div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-field-date-max form-item-field-date-max">
                <label for="edit-field-date-max">Max</label>
                <input data-drupal-selector="edit-field-date-max" type="text" id="edit-field-date-max" name="field_date[max]" value="" size="30" maxlength="128" class="form-text">
              </div>
            </div>
          </fieldset>
          <div class="js-form-item form-item js-form-type-select form-type-select js-form-item-sort-by form-item-sort-by">
            <label for="edit-sort-by">Sort by</label>
            <select data-drupal-selector="edit-sort-by" id="edit-sort-by" name="sort_by" class="form-select">
              <option value="field_date" selected="selected">Newest First</option>
              <option value="search_api_relevance">Best Match</option>
            </select>
          </div>
          <div class="js-form-item form-item js-form-type-select form-type-select js-form-item-sort-order form-item-sort-order">
            <label for="edit-sort-order">Order</label>
            <select data-drupal-selector="edit-sort-order" id="edit-sort-order" name="sort_order" class="form-select">
              <option value="ASC">Asc</option>
              <option value="DESC" selected="selected">Desc</option>
            </select>
          </div>
          <div class="js-form-item form-item js-form-type-select form-type-select js-form-item-items-per-page form-item-items-per-page">
            <label for="edit-items-per-page">Items per page</label>
            <select data-drupal-selector="edit-items-per-page" id="edit-items-per-page" name="items_per_page" class="form-select">
              <option value="10" selected="selected">10</option>
              <option value="20">20</option>
              <option value="30">30</option>
              <option value="40">40</option>
              <option value="50">50</option>
              <option value="All">View All</option>
            </select>
          </div>
          <div data-drupal-selector="edit-actions" class="form-actions js-form-wrapper form-wrapper" id="edit-actions"><input data-drupal-selector="edit-submit-newsroom-of-acquia-search" type="submit" id="edit-submit-newsroom-of-acquia-search"
              value="SEARCH" class="button js-form-submit form-submit">
          </div>
        </div>
      </div>
    </main>
  </div>
</form>

Text Content

Skip to main content

An official website of the United States government

Here’s how you know

Here’s how you know

The .gov means it’s official.

Federal government websites often end in .gov or .mil. Before sharing sensitive
information, make sure you’re on a federal government site.

The site is secure.

The https:// ensures that you are connecting to the official website and that
any information you provide is encrypted and transmitted securely.


Resource Navigation
 * Press Kit
 * CMSData
 * Contact
 * Blog
 * Podcast


 * About Us
 * Newsroom
 * Data & Research

opens in new window
Toggle Mobile Search
Close Search
Centers for Medicare & Medicaid Services


MAIN HEADER

 * About Us
 * Newsroom
 * Data & Research

Newsroom


NEWSROOM_NAVIGATION

 * Press Kit
 * CMSData
 * Contact
 * Blog
 * Podcast

 Search

 

 

Select search language:
English Español
Search newsroom articles
- Any -Site's default language (English)Interface text language selected for
pageEnglishSpanishNot specifiedNot applicable
Date
Min
Max
Sort by Newest FirstBest Match
Order AscDesc
Items per page 1020304050View All

FACT SHEET

MEDICARE ADVANTAGE RISK ADJUSTMENT DATA VALIDATION FINAL RULE (CMS-4185-F2) FACT
SHEET



Jan 30, 2023
 * Medicare Part C

Share

opens in new window opens in new window opens in new window

In a final rule released today, 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
will help CMS to protect the MA program (also known as “Medicare Part C”) 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.

MA Payment and the Role of RADV Audits

CMS contracts with private companies, called Medicare Advantage Organizations
(MAOs), to offer various health plan options for Medicare beneficiaries. These
MAOs provide all Medicare Part A and Part B benefits (also known as “Traditional
Medicare” or “Medicare Fee-For-Service” (FFS)), and most offer additional
benefits, such as Medicare drug coverage, beyond those covered under the
Medicare FFS program. Nearly 30 million individuals receive their Medicare
benefits through MA. CMS has a statutory obligation and fiduciary duty to ensure
payments in the Medicare program are accurate, including conducting oversight of
payments made to MAOs. This approach is well-established among other CMS
programs and ensures consistency in CMS’ oversight of the Medicare FFS and MA
programs.

Section 1853(a)(1)(C) of the Social Security Act (the Act) requires CMS to
risk-adjust payments made to MAOs. CMS pays each MAO a monthly amount for each
beneficiary enrolled in an MA plan, which is adjusted to account for differences
in health status amongst enrolled beneficiaries. This adjustment is referred to
as “risk adjustment.” Risk-adjusted payments are based on medical diagnoses
submitted by the MAOs that, by long-standing regulations, must be supported in
the Medicare enrollees’ medical records to ensure accurate payment. Risk
adjustment strengthens the MA program by ensuring that accurate payments are
made to MAOs based on the health status and demographic characteristics of their
enrolled beneficiaries, and that MAOs are paid appropriately for their plan
enrollees (that is, less for healthier enrollees who are expected to incur lower
health care costs, and more for less healthy enrollees who are expected to incur
higher health care costs).

Making accurate payments to MAOs is part of CMS’ responsibility to ensure
accurate payments across the Medicare program and ensures continued access to
benefits and services for people with Medicare while safeguarding federal
taxpayer dollars. Studies and audits done separately by CMS and the HHS Office
of Inspector General (OIG) have shown that medical records do not always support
the diagnoses reported by MAOs, which leads to billions of dollars in
overpayments and increased costs to the Medicare program. RADV audits are the
main corrective action for those improper payments. Through RADV audits, a
sample of beneficiary medical records are provided by MAOs, and CMS reviews
those records to verify that diagnoses reported for risk adjusted payments are
accurate and supported in the medical record. Risk adjustment discrepancies can
be aggregated to determine an overall level of payment error, which can then be
extrapolated. The HHS-OIG also undertakes audits of MAOs, similar to RADV
audits, as part of its oversight functions.  CMS can collect the improper
payments identified during those HHS-OIG audits, including the extrapolated
amounts calculated by the HHS-OIG.

Final Rule Policies

Extrapolation

Rather than applying extrapolation beginning for payment year (PY) 2011 audits
as we proposed, we are finalizing a policy not to extrapolate RADV audit
findings for PYs 2011-2017 and beginning extrapolation with the PY 2018 RADV
audit. As a result, CMS will only collect the non-extrapolated overpayments
identified in the CMS RADV audits and OIG audits between PY 2011 and PY 2017.
CMS is not adopting any specific sampling or extrapolation audit methodology but
will rely on any statistically-valid method for sampling and extrapolation that
is determined to be well-suited to a particular audit. However, any
extrapolation methodology adopted by CMS for RADV audits will be focused on MAO
contracts that, through statistical modeling and/or data analytics, are
identified as being at the highest risk for improper payments. While not
required, CMS will continue to disclose our extrapolation methodology to MAOs,
providing MAOs with the information sufficient to understand the means by which
CMS extrapolated the RADV payment error.

Extrapolation has historically been a normal part of auditing practice at CMS,
including in FFS Medicare, and CMS interprets our existing authority as
authorizing the use of sampling and extrapolation in RADV audits. It is also
expected that the use of extrapolation will incentivize MAOs to take meaningful
steps to reduce improper risk adjusted payments in the future.

FFS Adjuster

The rule also finalizes a policy, as proposed, that CMS will not apply an
adjustment factor (known as an FFS Adjuster) in RADV audits. As described in the
final rule, and consistent with a recent D.C. Circuit Court decision in
UnitedHealthcare Insurance Co. v. Becerra, 16 F.4th 867 (D.C. Cir. August 13,
2021, reissued November 1, 2021), cert. denied, 142 S. Ct. 2851 (U.S. June 21,
2022) (No. 21-1140), the requirement for actuarial equivalence in MA payments
applies to how CMS risk adjusts the payments it makes to MAOs and not to the
obligation to return overpayments for unsupported diagnosis codes, including
overpayments identified during a RADV audit. In addition, we do not believe that
it is reasonable to read the Act as requiring a reduction in payments to MAOs by
a statutorily set minimum adjustment in the coding pattern adjustment, while at
the same time prohibiting CMS from paying at those reduced rates by mandating a
FFS Adjuster for RADV audits.

The RADV final rule can be accessed at the Federal Register at
https://www.federalregister.gov/public-inspection/current

###

 * Previous
 * Next


RELATED RELEASES

 * CMS Announces Resources and Flexibilities to Assist with the Public Health
   Emergency in the State of Mississippi Due to Recent Storms
   Mar 28, 2023
 * 2024 Medicare Advantage and Part D Advance Notice Fact Sheet
   Feb 01, 2023
 * CMS Releases 2024 Advance Notice with Proposed Payment Updates for the
   Medicare Advantage and Part D Prescription Drug Programs
   Feb 01, 2023
 * CMS Issues Final Rule to Protect Medicare, Strengthen Medicare Advantage, and
   Hold Insurers Accountable
   Jan 30, 2023
 * CMS Announces Increase in 2023 in Organizations and Beneficiaries Benefiting
   from Coordinated Care in Accountable Care Relationship
   Jan 17, 2023


CONTACT US

CMS News and Media Group
Catherine Howden, Director

Media Inquiries Form
202-690-6145


GET EMAIL UPDATES

Sign up to get the latest information about your choice of CMS topics in your
inbox. Also, you can decide how often you want to get updates.

SIGN UPopens in new window


CMS & HHS WEBSITES

 * Medicare.govopens in new window
 * Medicaid.govopens in new window
 * InsureKidsNow.govopens in new window
 * HealthCare.govopens in new window
 * HHS.govopens in new window


HELPFUL LINKS

 * Acronyms
 * Archive
 * Contacts
 * Glossary
 * Privacy policy
 * Privacy settings


RSS FEEDS

 * NewsroomRSS Feeds
 * BlogRSS Feeds
 * PodcastRSS Feeds

opens in new window opens in new window

A federal government website managed and paid for by the U.S. Centers for
Medicare & Medicaid Services.

7500 Security Boulevard, Baltimore, MD 21244

opens in new window opens in new window opens in new window



TOOLS

 * Web policiesopens in new window
 * Plain languageopens in new window
 * No Fear Actopens in new window
 * Freedom of Information Actopens in new window
 * Inspector Generalopens in new window




Feedback