A judge has tossed the entire Risk Adjustment Data Validation rule, throwing CMS’ plans to audit MA insurers for overcoding into great doubt.
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Millions of Americans feel confused and frustrated in their search for quality healthcare coverage.
Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change.
Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare.
Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name.
Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare.
Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.
About The Episode:
On this episode, Marc discusses a court decision to toss the entire Risk Adjustment Data Validation rule in Medicare Advantage. This throws CMS’ plans to audit MA insurers for overcoding into great doubt.
Key Takeaways:
A federal court has vacated the 2023 Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) audit rule finalized during the Biden years.
The court nullified the entire rule not just portions of it.
The decision was not unexpected. The Biden administration included so many far-fetched and indefensible provisions.
At the same time, it is a bit of a shocker as it throws the Trump administration’s plans for a 100% RADV audit commitment into great flux.
Humana challenged the rule, arguing the agency did not follow the regulatory act and various parts were unlawful, including extrapolation, retroactivity, and the omission of a factor that took into account differences between the traditional program and MA.
The court in the RADV case found that CMS did not follow the procedural requirements and vacated the rule entirely without ruling on specific arguments from Humana.
The government wanted to conduct 100% audits on each contract each year given major overpayments to MA plans in part due to risk adjustment overcoding.
But studies seem to prove that a small subset of larger plans have the bad practices and gain disproportionate revenue from overcoding.
Audits will be hard to conduct with no rule, but CMS will come back to try to implement a new one.
Further, CMS and Congress could see overpayment reform that could be far more injurious than the audits for most plans.
Plans should undertake a number of potential actions, including reforming their risk adjustment coding practices and endorsing reasonable reforms.
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Resources:
The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance
