Risk Adjustment

Forecasting Future Enforcement and the Implications for the Compliance and Legal Landscape

October 13, 2022 11:00am

Elizabeth Lippincott
Strategic Health Law

Teresa Mason
Member of the Firm
Epstein Becker & Green P.C.

Julie Nielsen
Managing Director
Berkeley Research Group LLC

Risk adjustment is being heavily scrutinized by government agencies, in an effort to prevent and address fraud, waste and abuse in the administration the Medicare Advantage program. For MAOs, navigating the complexities of risk adjustment to ensure data accuracy and compliance is of the utmost importance—as a failure to do so can lead to costly consequences. This session will examine the influence of the legal landscape, key oversight channels, and compliance best practices. 

  • Analysis of oversight channels
    • CMS RADV audits
    • OIG Targeted and RADV-like audits
    • Whistleblower FCA litigation
    • DOJ perspective on risk adjustment as revealed in FCA litigation
  • Insights on the relevance of actuarial equivalence and current applications in law
    • Overpayment rule
  • Examining how plans calculate bid rates and risk score projections
  • Forecasting potential outcomes for the CMS’ proposed rule and the implications for MAOs
    • Identifying calculation modifications and how to align internal processes to ensure compliance
    • How does it ultimately impact plans who are selected for RADV audit
  • Developing compliance oversight of risk adjustment in the absence of cohesive guidance
  • Determining what immediate corrective actions can be taken when FWA is detected