CMS released the Medicare Program; Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, Medicare Parts A, B, C, and D Overpayment Provisions of the Affordable Care Act and Programs of All-Inclusive Care for the Elderly; Health Information Technology Standards and Implementation Specifications. See proposed rule changes here. 

Here are proposed HHS RADV changes that may impact your plan:  

  • Beginning with 2022 benefit year, change the materiality threshold established under § 153.630(g)(2) for random and targeted sampling from $15 million in total annual premiums statewide, to 30,000 total billable member months statewide, calculated by combining an issuer’s enrollment in a state’s individual non-catastrophic, catastrophic, small group, and merged markets, as applicable, in the benefit year being audited. 
  • Shorten window to confirm findings of the second validation audit (SVA) if applicable, or file a discrepancy report to dispute SVA findings, to within 15 calendar days of notification by HHS, beginning with 2022 benefit year. 
  • Solicit comments on discontinuing use of the lifelong permanent condition list and the use of Non-EDGE Claims in HHS RADV 

Here’s what you should consider now: 

  • How will the move from $15M in annual premiums to 30,000 billable member months affect your organization? What about the potential for smaller HIOS IDs to be randomly selected for HHS RADV audit?  
  • Are you prepared to complete discrepancy reviews and report disputes to CMS within 15 days?  What resources will you need to comply with a 15-day review window?  
  • How will discontinuation of the Life Long Permanent Condition (LLPC) list and/or the use of Non-EDGE Claims (NEC) affect your overall validation rate? Have you done the analytics, reviewed EDGE submission challenges/errors, reviewed prior use NECs and/or necessary medical record documentation reviews for your LLPCs to figure out how these change may impact your audit results?  

ATTAC has deep experience performing large-scale HHS RADV audits for ACA issuers and Medicare plans. Issuers trust us to provide critical feedback via our web-based portals, gap reporting and analytics. We are HITRUST certified and securely manage all data and reporting. Contact us to learn more about how we can help you navigate the 2023 proposed changes.