The intention for developing RADV audits was to develop a checks and balances to ensure reimbursement payment accuracy for Medicare Advantage Organizations (MAOs).

There’s a history of CMS addressing payment accuracy in the Medicare space that dates back to the 80’s with the prospective payment system, PPS, and in the late 90’s with the Balanced Budget Act. The first RADV audit for MAOs wasn't performed until 2007. The initial audits determined that MAOs were being significantly overpaid which justified the 2011 proposed rule that suggested overpayments should be extrapolated, in other words, overpayments should be returned to the Centers for Medicare and Medicaid Services (CMS).

Over the years, CMS has explored different ways to determine the error rate of MAO overpayment. In the most recent 2023 Final Rule, CMS has released their go-forward plan to extrapolate beginning in payment year 2018, however, no specific methodology for error rate determination has been defined, nor has a commencement date been announced. Plans can expect to be notified prior to extrapolation so they can forecast.

Health plans need to implement a strong risk mitigation program to ensure reimbursement accuracy.

Tune in to this episode to discover: 

• The impact to smaller plans
• Industry-wide changes in response to the Final Rule
• How plans will deal with the potential reimbursement loss
• Ways to improve reimbursement accuracy

About Our Guest
Amanda Proctor has over 13 years in risk adjustment coding and specializes in risk mitigation, coding quality and education. She holds multiple certifications in coding and is an AAPC approved instructor.