CMS is planning to continue its Medicare Advantage audits and overpayment recoveries, according to a Jan. 27 memo.
While federal estimates point to $17 billion in overpayments each year, the last major risk-adjustment data-validation recovery took place in payment year 2007. From payment years 2011 to 2013, CMS identified overpayment rates between 5% and 8%.
In May, CMS said it hoped to tackle its backlog from previous audits and wrap up audits that ran from 2018 to 2024. The agency planned an “aggressive” MA audit expansion by hiring more medical coders, but, as of September, progress was unclear. Now, CMS confirmed it is prioritizing those recoveries and unfinished audits.
“Recoveries on these amounts will begin soon,” the memo said.
Plan year 2020 audits were slated to begin by February this year, as well.
Based on stakeholder feedback, CMS is also restoring its medical record submission window to five months, launching audits about every three months, maintaining a two-record cap per hierarchical condition category and clarifying how smaller plans would be less likely to face a 200-enrollee sample.
CMS anticipates leveraging an AI-powered medical coder support tool to expedite reviews. The technology will be fully tested before audit implementation, and coding decisions that may lead to overpayment determinations will stem from human certified medical coders, the memo noted.
CMS also said it is working to “further support transparency,” with plans to redesign its RADV webpages. CMS requested that stakeholders submit payment year audit questions, too, “so we can continue to identify and resolve pain points in real time.”
In November, HHS appealed a Texas federal court’s judgment that vacated parts of the program’s final rule. This limited CMS’ authority to extrapolate sample results to an insurer’s entire MA population. Despite the ongoing legal uncertainty, CMS said it will comply with the court order while forging ahead with forthcoming audits.
MedPAC estimated MA payments would reach $76 billion more than what fee-for-service spending would have been in 2026. In the proposed 2027 payment rule, CMS pitched excluding diagnosis information from “unlinked chart review records” from risk scoring, as well.
