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AHIP Comments On CMS Proposal To Change Medicare Advantage Risk Adjustment Data Validation Audits

by Kristine Grow

October 30, 2018

WASHINGTON, D.C. – Matt Eyles, president and CEO of America’s Health Insurance Plans (AHIP), issued this statement following the Centers for Medicare & Medicaid Services’ (CMS) proposal to change a long-standing position on the legally appropriate way to estimate contract-wide documentation issues in Medicare Advantage (MA) plans in Risk Adjustment Data Validation (RADV) audits:

“Americans deserve a strong Medicare Advantage program. MA continues to deliver better value, more choices, and higher levels of satisfaction for seniors and other Medicare beneficiaries than traditional Medicare. Health insurance providers are committed to delivering real results.

‘To deliver for beneficiaries, insurance providers must have clarity and certainty regarding the MA program. AHIP supports program oversight to protect taxpayers and beneficiaries – but audits must be conducted in ways that are methodologically and actuarially sound, and are legally appropriate, to avoid highly inaccurate findings that could undermine the ability of MA plans to deliver for the 20 million Americans they serve.

“We are performing a comprehensive assessment of how CMS’ proposal to modify how they conduct RADV audits without a fee-for-service adjuster would impact beneficiaries and program stability. We are greatly concerned that the proposal reverses a long-standing position – held by both the agency and other stakeholders – that the adjuster is legally and actuarially required. We are further concerned about significant methodological issues, which according to a recent study by the Wakely Consulting Group, would cause highly random and arbitrary results. CMS’ retroactive application of this proposed rule would exacerbate these problems.

“Health insurance providers are accountable to the seniors they serve on Medicare Advantage as well as the taxpayers who pay for it. In our comments, AHIP will offer solutions for how we can work together to improve coding, deliver better transparency, and ensure appropriate payments as we continue to serve the health needs of MA enrollees.”