Beginning immediately, the Centers for Medicare and Medicaid Services is auditing all eligible Medicare Advantage contracts in what the agency is calling a significant expansion of its efforts.
The agency will expand its workforce of medical coders from 40 to about 2,000 by Sept. 1 to take care of a backlog. This will expedite the completion of audits for payment years 2018 through 2024, CMS said.
In addition, CMS said it plans to use enhanced technology to review medical records and flag unsupported medical diagnoses. The technology will enable CMS to increase the number of audits from about 60 Medicare Advantage plans a year to all eligible MA plans each year, or approximately 550 MA plans.
Using technology and an expanded workforce, CMS expects to increase auditing numbers from 35 records per health plan, per year to between 35 and 200 records per health plan, per year based on the size of the health plan.
CMS said it plans to complete all remaining Risk Adjustment Data Validation (RADV) audits for payment years 2018 to 2024 by early 2026.
WHY THIS MATTERS
MA plans may overbill the government by approximately $17 billion annually, according to CMS. The Medicare Payment Advisory Commission (MedPAC) estimates this figure could be as high as $43 billion per year.
The last significant recovery of MA overpayments occurred following the audit of payment year 2007.
Audits for payment years 2011–2013 found between 5% and 8% in overpayments, CMS said.
CMS is collaborating with the Department of Health and Human Services Office of Inspector General (HHS-OIG) to recover uncollected overpayments identified in past audits.
THE LARGER TREND
The RADV final rule released in 2023 announced policies to improve program integrity and payment accuracy in the Medicare Advantage program.
Medicare Advantage plans receive risk-adjusted payments based on the diagnoses they submit for enrollees. There are higher payments for patients with more serious or chronic conditions.
To verify the accuracy of these claims, CMS conducts RADV audits to confirm that diagnoses used for payment are supported by medical records.
ON THE RECORD
"We are committed to crushing fraud, waste and abuse across all federal healthcare programs," said CMS Administrator Dr. Mehmet Oz. "While the administration values the work that Medicare Advantage plans do, it is time CMS faithfully executes its duty to audit these plans and ensure they are billing the government accurately for the coverage they provide to Medicare patients."
Email the writer: SMorse@himss.org