CMS is proposing a standard appeals process for risk adjustment data validation audits in Medicare Advantage.
CMS issued its 2025 Medicare Advantage proposed rule on Nov. 6. In the rule, CMS proposed MA organizations be able to request a medical record review determination appeal or payment error calculation appeal, but not both at the same time.
Under the proposed rule, plans can only request a payment error calculation appeal after the medical record review is completed. The proposed rule would also establish that if the CMS administrator does not accept or decline an appeal within 90 days of receiving the appeal, the audit becomes final.
Under current rules, appeals move through the medical record and payment error process at the same time, which can result in inconsistent decisions, CMS said in its proposed rule.
"This has the potential to cause burden, confuse MA organizations, and negatively impact the operations and efficiency of CMS's appeals processes," the agency said.
In January, CMS said it will strike the fee-for-service adjuster from risk adjustment data validation audits, a tool that would have calculated a permissible level of payment errors and limited audit recoveries to payment errors above that level. Humana is challenging the new RADV rule in court.
The agency has published RADV audits of several Medicare Advantage plans this year, including an estimated $117 million in overpayments received by Humana and $25.5 million received by Aetna.
The proposed rule is open for comment until Jan. 5.