Frier Levitt Partner Jason N. Silberberg was quoted in a Part B News article titled, “MAOs More Motivated To Audit; 4 Tips Will Help Your In-Person Process” by Roy Edrosa.
As CMS rolls out new standards for audits of Medicare Advantage organizations (MAOs), providers who contract with those organizations expect potential aggressive audits and increased liability for government takebacks. The final Part C rule issued by CMS on February 1, 2023, has eliminated the fee-for-service “adjuster” in the Risk Adjustment Data Validation (RADV) process, making overpayment determinations less accurate for MAOs. The rule also allows RADV auditors to extrapolate claims, significantly increasing MAOs’ liability to government takebacks. Jason highlights that MAOs may seek to shift this liability to providers by intensifying diagnosis code-related audits and clawbacks.
MAO audits, traditionally conducted to ensure accurate billing and coding, are now expected to scrutinize provider records more aggressively. With the potential for repayment obligations imposed on MAOs, providers may face increased pressure to return funds, particularly if their records are reviewed and diagnoses are unsupported by medical records.
Experts advise providers to cooperate with audits as required by regulations and contracts but emphasize the importance of understanding and protecting their rights. Contract negotiation may be limited for smaller practices, but larger provider organizations could have more bargaining power in terms of the audit process.
View the article live on Part B News: https://pbn.decisionhealth.com/Articles/Detail.aspx?id=547154
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