Big health insurers who spoke at the J.P. Morgan Healthcare Conference are gearing up to battle the Biden administration once it finalizes its plan for auditing Medicare Advantage, which is expected to happen next month.
Executives from Humana, Centene, and CVS Health-Aetna aired concerns about the forthcoming final rule on the audits, known as risk adjustment data validation, or RADV. Medicare has been mulling the update for years, but the process has been held up by industry opposition. Enhanced audits could potentially force insurers to repay tens of millions of dollars for a single audit. Recently, though, Medicare gave itself a firm deadline; It will issue a final rule on the matter by Feb. 1.
The federal government pays Medicare Advantage insurers depending on how sick their members are, a determination the insurers themselves make through a scoring system called risk adjustment. There’s widespread concern that insurers are inflating those scores in order to get paid more, a suspicion the Department of Health and Human Services’ Office of Inspector General has confirmed in several cases.