More MA audits on the way?

Wednesday, December 30, 2015

WASHINGTON – CMS is considering expanding its RAC program for Medicare Advantage, according to a draft scope of work published by the agency.

Currently, CMS audits 30 MA contracts per payment year, about 5% of the total number of contracts. Now it is considering increasing the number of contracts that are subject to some type of risk adjustment data validation audit, which validates the accuracy of diagnosis data submitted by MA organizations.

“Our ultimate goal is to have all MA contracts subject to either a comprehensive or condition-specific RADV audit for each payment year,” the agency states in the draft.

Errors and omissions in diagnosis data submitted by MA organizations are the drivers of the 9.5% improper payment rate in Medicare Part C, according to CMS.

The Patient Protection and Affordable Care Act of 2010 requires expansion of the RAC program to Medicare Part C and Part D, the agency states.

CMS is accepting comments on the draft until Feb. 1.