Navigating the 2023 CMS Program Audit: Are You Ready?

CMS has initiated routine program audits by sending engagement letters to Medicare Advantage organizations, prescription drug plans and Medicare-Medicaid plans. Are You Audit-Ready? If your plan receives an engagement letter, are you prepared to respond within 15 business days, or do you feel nervous and hope you

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How to Prepare Your Medicare Advantage Initial or Service Area Expansion Application for CY 2024 & Beyond

CMS requires applicants to demonstrate they have a sufficient network of contracted providers before an initial or service-area expansion application is approved. In addition, for CY 2024, CMS will adopt regulations explicitly permitting it to deny applications based on an applicant’s failure to meet network adequacy criteria. Plans

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Medicare Advantage RADV Final Rule Changes: With an Expected Audit Recovery of Nearly $5B in Next 10 Years, Will Your Plan Face an Audit?

The Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) audit is a vital process conducted by CMS to ensure the correctness of payments to MA plans. CMS determines monthly payments based on the health and demographic characteristics of each member, as determined by the Hierarchical Condition Category

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RADAR on Medicare Advantage | With Final RADV Rule Out, MAOs Are Advised to Clean Up Risk Adjustment Practices

Medicare Advantage organizations may not have gotten the outcome they were hoping for in CMS’s recently finalized Risk Adjustment Data Validation rule, but industry experts say they weren’t surprised by the position CMS ultimately took after years of pressure to close out RADV audits and recover identified

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