As Medicare Advantage has grown significantly, program sustainability and potential improper payments to Medicare Advantage organizations have come under extensive review. The Centers for Medicare and Medicaid Services (CMS) on February 1, 2023, issued a final rule updating Medicare Advantage Risk Adjustment Data Validation program audit methodologies and related policies.

The rule is effective April 3, 2023.

In the final rule, CMS has established substantial changes to how the risk adjustment program works. This fact sheet provides highlights of the final audit methodology, what this means for Medicare Advantage organizations, and what these organizations should do now.

Health plans must prepare to repay potential improper payments made since 2018, support new audit requirements, and mitigate risk of near-term improper payments in current and future payment years.

Read the Fact Sheet

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