2025-05-22-Bernstein-快速解读医疗保险和医疗补助服务中心（CMS）将扩大风险调整数据验证（RADV）审计范围至所有医疗保险优势（MA）计划-这能否应对未来监管风险_11页_491kb

CMS Expands RADV Audits for Medicare Advantage Plans

Key Announcement

CMS announced a significant expansion of its Risk Adjustment Data Validation (RADV) audits to cover all eligible Medicare Advantage (MA) contracts for payment years 2018 through 2024. Previously, audits were limited to subsets of plans. The move aims to complete the existing audit backlog and enhance oversight over risk-adjusted payments, with completion expected by early 2026, using additional resources and advanced technologies.

Audit Details and Resources

RADV audits verify the accuracy of risk-adjusted Medicare Advantage payments by examining medical records and coding. CMS previously identified overpayments of 5% to 8% in audits for pay years 2011–2023.

• Resources deployed: CMS will expand its workforce from 40 medical coders to 2,000, implement new systems/technologies, and allocate extra funding to increase audit volume.
• Scope: Audits now cover all 550+ eligible MA plans annually (up from ~60 per year), including retrospective extrapolation of findings starting in 2025 based on past errors.

Financial Implications

The expanded audits could lead to substantial financial impacts for MA plans and CMS:

• Clawbacks: Anticipated one-time repayments, such as $479M in 2025 and a cumulative $4.7B over the decade, due to recoveries of prior overpayments. These may affect balance sheets, potentially recorded as a one-time charge or excluded from adjusted earnings.
• Forward effects: Reduced expected premium rates could slow MA membership growth. Insurers may cut ancillary benefits to offset lower payments, as projected net rate increases are around 2% but incorporate this risk.

Analyst Opinions

Analysts view this as increasing one-time exposure from clawbacks but reducing risk from further regulatory actions. The enhanced audit function is seen as comprehensive, providing stability in risk adjustment and payments for MA.

Investment Implications

The report includes stock ratings and target prices:

• Outperform: AGL (-$7.50), CNC ($)86, HUM ($)313, MOH ($)414, UNH ($)377
• Market-Perform: CI, CVS, ELV, HCA, RATE 25-383
  Cases are rated for sectors like healthcare services and financials.

Background and Context

RADV audits were already underway but limited to certain plans since CMS first proposed changes in 2012 and 2018. The new approach includes extrapolation methodologies, estimated to recover billions, and may influence coding practices to reduce ongoing overpayments.