Federal prosecutors from the Department of Justice (DOJ) are prosecuting numerous large Medicare-Advantage Organizations (MAOs) under the False Claims Act. Simultaneously, auditors at the USDHHS Office of the Inspector General (OIG) have been conducting several “cookie-cutter” audits of risk adjustment diagnosis code submission accuracy at many other MAOs.
Although the OIG audits differ methodologically from traditional Risk Adjustment Data Validation (RADV) audits (the Centers for Medicare & Medicaid Services [CMS] has not finalized a single RADV audit since 2007), OIG risk adjustment audits are still audits. Each one has reached the same conclusion: “[the MAO] did not submit some diagnosis codes to CMS for use in the risk adjustment program in accordance with Federal requirements.”
For more information, refer to the New York Times article: Medicare Advantage Fraud Allegations.
While CMS has been uncertain about finalizing RADV audits since issuing a Notice of Proposed Rulemaking on November 1, 2018 (83 FR 54982), it now appears that CMS will release its final RADV rules on or before February 1, 2023.