Audits, Risk Adjustment Formula

The Trump Administration Implements Aggressive Medicare Advantage Plan Audits

Groom Law Group, Chartered on 6/12/2025

On May 21, 2025, the Centers for Medicare & Medicaid Services (“CMS”) announced its intent “to crush[] fraud, waste, and abuse across all federal healthcare programs” through aggressive audits of Medicare Advantage (“MA”)...more

CMS Medicare Advantage RADV Final Rule: No Fee-For-Service Adjuster, May Extrapolate Audit Findings Beginning with PY 2018

Groom Law Group, Chartered on 2/24/2023

More than four years after it was proposed, on February 1, 2023 the Centers for Medicare & Medicaid Services (CMS) published the long-awaited risk adjustment data validation (RADV) Final Rule (Final Rule) that will affect...more

New CMS Rule Requires Extrapolation of Medicare Advantage RADV Audit Findings

Perkins Coie on 2/15/2023

The Centers for Medicare and Medicaid Services (CMS) published its final rule regarding the Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) program in early February 2023. Among other matters, the final rule...more

CMS Releases Final Rule for Risk Adjustment Data Validation Audit Methodology

Ballard Spahr LLP on 2/1/2023

On January 30, 2023, CMS posted for inspection a final rule describing its Risk Adjustment Data Validation audit methodology (the Final RADV Rule). As we have discussed in prior alerts, the finalization of the RADV Rule,...more

[Webinar] Adjusting the Risk for Medicare Advantage: Recent Enforcement Trends and Litigation Involving Medicare Advantage Risk...

Wiley Rein LLP on 6/14/2021

The Department of Justice (DOJ) continues to concentrate on risk adjustment programs of payers with Medicare Advantage Organizations (MAO) as a prime enforcement target. One particular area of focus, both civilly and...more

Blog Series: CMS Proposed Rule on Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug Benefit,...

Sheppard Mullin Richter & Hampton LLP on 10/30/2018

On October 26, 2018, the Centers for Medicare and Medicaid Services (“CMS”) released for viewing a proposed rule that includes significant changes for Medicare Advantage organizations (“MAOs”), Part D prescription drug plan...more