While justified, there is some question about whether the new RADV audits will be fair to MA plans.

About The Podcast:

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 the new 100% RADV audits. While justified, there is some question about whether the new RADV audits will be fair to MA plans.

Key Takeaways:

CMS announced it will audit all Medicare Advantage (MA) contracts for each payment year. How it will ramp up staff and technology to hit the aggressive announcement is another question.

Opponents of MA call out dubious numbers on the magnitude of overpayments, but there is some risk adjustment abuse by a small number of plans that disproportionately benefit.

About half of contracts have been noticed for RADV audits in payment year 2019.

The 2023 RADV rule is controversial and being challenged by plans. The new audit process adds to the controversy.

CMS will use a suspect approach and target diagnosis codes for HCC risk adjustment clusters most at risk of abuse.

Fewer records can now be submitted, which ups the ante on accuracy, timeliness, and completeness during the submission period.

The suspect sample audit approach and extrapolation of penalties should be a major concern.

Will the industry end up worse off with the suspect approach than a more comprehensive one?

Does the government now conduct RADV audits in an Elon Musk, “DOGE-like” approach, storm-trooping for maximum recoupment to hit lower spending targets rather than a fair and transparent process rooted in real program integrity?

Other reforms could also be implemented.

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The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance