CMS to Expand RACs to Medicare Advantage

January 4, 2016
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Rick Gawenda
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The Centers for Medicare and Medicaid Services (CMS) has issued a draft Statement of Work (SOW) to solicit comment on, and interest in, CMS entering into a contract with a Recovery Audit Contractor (RAC) to identify underpayments and overpayments and recouping overpayments associated with diagnosis data submitted to CMS by Medicare Advantage Organizations.

Errors and omissions in the diagnosis data submitted to CMS by Medicare Advantage Organizations are the drivers of the 9.5% improper payment rate in Medicare Part C. Currently, CMS audits 30 Medicare Advantage Organization contracts (approximately 5%) per payment year. CMS is considering contracting with a Part C RAC to increase the number of Medicare Advantage Organization contracts that are subject to some type of Risk Adjustment Data Validation (RADV) audit for each payment year. Our ultimate goal is to have all MA contracts subject to either a Comprehensive or Condition‐Specific RADV audit for each payment year.

This draft SOW describes the Part C RAC’s role in the existing RADV audit process, referred to herein as the Comprehensive RADV audits, and their role in additional audits of diagnosis data submitted to CMS by Medicare Advantage (MA) Organizations, referred to herein as Condition‐Specific RADV Audits. To read the draft SOW, click

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