May 31, 2016

Expect Changes to Risk Adjustment Oversight as CMS Feels Heat From GAO

In a May 9 report, the Government Accountability Office (GAO) criticized the Centers for Medicare and Medicaid Services (CMS) for failing to recover overcharges stemming from faulty payment coding in the Medicare Advantage (MA) Risk Adjustment Program. Mike Adelberg, senior director for FaegreBD Consulting, authored a client alert that assessed the potential fallout from the GAO’s criticism, detailed CMS’s attempts to audit its risk-adjustment data, and provided a broader overview of the risk-adjustment program and its protocols. 

A Medicare Advantage News article quoted an excerpt from the alert in which Adelberg argued that the GAO report will likely trigger remedial action on CMS’s part.  

“There is a long history of GAO reports, often in concert with increased Congressional attention, spurring CMS to implement difficult program changes,” Adelberg said. “While CMS, in its official response, pushed back on the GAO on some technical issue, it concurred with the GAO’s high level findings. For MA plans and their vendors, this GAO report should be considered less for its content than for the action it foreshadows, potentially as early as next year.”

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