Medicare Advantage Audits Face New Legal Challenge as CMS Appeals RADV Rule Vacature
The ongoing scrutiny of Medicare Advantage (MA) plans took a new turn Friday as the Centers for Medicare & Medicaid Services (CMS) announced its appeal of a September court decision. This decision vacated the Medicare Risk adjustment Data Validation (RADV) rule, a policy designed to curb overpayments to MA insurers. The appeal comes amidst heightened regulatory focus on MA financial practices and a commitment to increased audits.
What Happened with the RADV rule?
finalized in early 2023, the RADV rule aimed to allow CMS to identify potential overbilling by MA plans. Here’s how it was intended to work:
* CMS would sample diagnoses of MA beneficiaries.
* If discrepancies were found – suggesting inflated illness reporting to justify higher reimbursement – the agency would extrapolate those findings across the entire MA contract.
* This would enable CMS to recoup an estimated $4.7 billion in overpayments over a decade.
Though, the rule faced immediate legal opposition. Humana, a leading MA provider, filed a lawsuit against the Department of Health and Human Services (HHS) in September 2023, arguing the rule was flawed.
Humana’s core Argument
Humana’s challenge centered on CMS’s removal of a “fee-for-service adjuster” from the final rule. This adjuster was originally intended to ensure MA beneficiaries received comparable payments to those in traditional medicare.
The insurer argued that eliminating the adjuster could lead to underpayment of MA plans.Critically, Humana contended that CMS didn’t provide adequate industry notice regarding this meaningful change.
Court Ruling and CMS’s response
Judge Reed O’Connor of the U.S. District Court for the northern District of Texas sided with Humana, vacating the RADV rule. This was a major victory for MA insurers. Now, CMS is appealing this ruling to the Fifth Circuit Court of Appeals. The agency has yet to publicly detail the grounds for its appeal, declining to comment on ongoing litigation.
Why This Matters to You
This legal battle unfolds against a backdrop of growing concern over MA spending.A recent report from the Medicare Payment Advisory Commission (MedPAC) revealed that medicare spends approximately $84 billion more annually on MA enrollees compared to those in traditional fee-for-service Medicare. this difference is largely attributed to:
* Favorable Selection: MA plans often attract healthier beneficiaries.
* coding Intensity: A tendency to utilize more detailed (and perhaps higher-reimbursing) diagnostic codes.
CMS Administrator dr.Mehmet Oz has repeatedly emphasized the need to address these overpayments. The agency is actively increasing its audit capacity and working through a backlog of previous reviews. You can expect to see:
* Increased Audits: CMS plans to significantly expand its auditing of MA plans.
* Heightened Scrutiny: A more rigorous review of billing practices and diagnostic coding.
* Focus on Accuracy: A push for more accurate risk adjustment and reimbursement.
Looking Ahead
The outcome of the Fifth Circuit appeal will significantly impact CMS’s ability to recoup overpayments from MA plans. The agency’s commitment to increased oversight signals a continued focus on financial integrity within the MA program. As a beneficiary, understanding these developments can help you navigate the complexities of medicare Advantage and ensure you receive the appropriate level of care and coverage.
resources:
* CMS to increase Medicare Advantage audits to crack down on overpayments
* Federal regulators crack down on Medicare advantage audits poised to claw back billions
* Humana sues HHS over Medicare Advantage risk adjustment audits
