MA Plans Resist RADV Final Rule

After four long years of anticipation and two delays, CMS finally released the regulations for the Medicare Advantage (MA) RADV program - an essential audit and monitoring instrument used to control MA payments. Through the RADV program, CMS is able to detect any improper payments made to MA organizations due to medical diagnoses that do not have supporting evidence within a beneficiary's medical records.

The Monday afternoon following the release of the final rule, Dara Corrigan of CMS' Center for Program Integrity held a conference call with MA organizations to discuss how these measures will ensure sustainability and strength in Medicare programs. She stated that the policies are necessary common sense steps that were taken to help secure 30 million senior's futures. 

As the primary way that CMS ascertains unreasonable payments, RADV audits are essential. Since Medicare pays more for people with greater medical needs, it is critical to ensure that submitted MA claims accurately reflect this information. Through these audits, it can be verified whether or not the diagnosis on file in medical records matches up with what is being claimed by providers. 

Unfortunately though, there have been cases where medical documentation does not support the official diagnosis - which just adds a further financial strain onto Medicare as a whole.

Corrigan further mentioned that the ultimate policies echo those of the Medicare FFS program. “In 2011, we managed to reclaim almost $11 billion for the Medicare Trust Fund by way of our medical review on FFS program” she stated. She then emphasized her point despite apprehensions from stakeholders claiming that CMS does not think RADV final rule will affect premiums or benefits for MA participants."

Opposition

Insurance companies were enraged when the new rule was unveiled. As MA continues to gain immense popularity, with over 30 million beneficiaries this year alone, it is highly likely that these industry advocates will legally retaliate against the regulation.

The Alliance of Community Health Plans (ACHP) expressed profound displeasure with the final risk adjustment data validation rule, asserting that it would place an unfeasible strain on smaller regional plans operating in a precarious financial position. ACHP has continually urged the Administration to reopen this regulation for public comment in order to meaningfully improve program integrity within MA.

The insurer advocacy group AHIP has contested the legality of this regulation. "This rule is unlawful and fatally flawed, so it should have been withdrawn instead of finalized," exclaimed Matt Eyles, president at AHIP in a statement. This proposed law will prove detrimental to seniors, worsen health equity disparities amongst those who require care most urgently and increase prices for both taxpayers and elderly citizens alike; in addition to decreasing benefits available through MA plans while diminishing plan options further down the road.

Earlier this month, Bruce Broussard of Humana expressed his dismay about the new regulation that removed adjuster requirements. To assess how these audits might affect their most successful sector - MA - he and his team have been considering all possible options due to a lack of clarity on the methodology of the rule. Sarah London, the CEO of Centene, concurred with his remarks and highlighted that the removal of fee-for-service adjustments and lack of clarity around its methodology has left numerous queries as to how successful this approach will be in reality.

The New Policy Includes

Extrapolation With The Payment Year 2018 RADV Audit

In their proposed rule, CMS initially intended to extrapolate data from the audits that began in 2011. However, they have now decided only to collect non-extrapolated overpayments identified between payment years of 2011 and 2017 – a massive relief for some professional organizations who anticipated that billions of dollars would be demanded back from audited plans since 2011. As opposed to a predetermined sampling or audit process, the agency will adhere to any statistically-rational method that is found suitable for a particular examination. Additionally, CMS confirmed during their stakeholder call and in the final ruling that whichever extrapolation process they adopt for RADV audits shall focus on MAOs with the highest risk of erroneous payments.

At CMS, extrapolation has been a well established auditing technique utilized in FFS Medicare for many years. This process is expected to instill meaningful change within MA organizations and encourage them to reduce the number of erroneous risk adjustment payments that occur recurrently.

FFS Adjuster Eliminated  

CMS is staying true to its proposal and will not be using the FFS Adjuster in RADV rule. This decision falls in line with UnitedHealthcare Insurance Co. v Becerra, which stated that actuarial equivalence provisions should only apply when adjusting payments made to MA organizations and not refunds of improper payments due to unsupported diagnosis codes uncovered through a RADV audit.

Moreover, the agency claimed that it is unfair to reduce payments made to Medicare Advantage Organizations due to a set of minimum adjustments in coding patterns while at the same time prohibiting CMS from reinforcing appropriate documentation requirements through requests for offsets in recovery amounts calculated during their audits.

Additionally

Sean Creighton, a renowned expert in Risk Adjustment policy and Managing Director of Avalere Health, highlighted the challenges MA industry will face due to the final RADV rule. He noted that "the lack of FFS adjuster forces providers to adhere to an arduous documentation standard at a time when CMS and plans are striving towards reducing administrative activities."

Medicare recipients who have enrolled in MA plans could possibly experience a decreased number of benefits, including dental care, vision and hearing assistance, as well as condition-related coverage that might be taken away," he declared.

ForeSee Medical offers risk adjustment decision support at the point of care. The OIG has published reports that concluded that payer retrospective chart reviews raise concerns related to validity of diagnoses. When medical groups code accurately and completely by either using a prospective or concurrent review process, codes do not require the same intensity of retrospective review by payers. Doing it right the first time may help plans better manage RADV audits and reduce the risk of erroneous payments.

Investing in risk adjustment software with artificial intelligence to automate processes, enables better data analysis, and provides more accurate data interpretation by using sophisticated algorithms which can connect disparate pieces of data together. Risk adjustment software from ForeSee Medical helps organizations meet their compliance requirements and reduces the need for extra coding resources. ForeSee Medical's AI-powered solution is cost effective and provides a much needed competitive advantage to risk-bearing organizations with regard to the speed and accuracy of risk adjustment coding.

Blog by: The ForeSee Medical Team