Federal prosecutors working for the Department of Justice (DOJ) are prosecuting many large Medicare-Advantage Organizations (MAOs) under the False Claims Act. At the same time, auditors at the USDHHS Office of the Inspector General (OIG) have been conducting numerous “cookie-cutter” audits of risk adjustment diagnosis code submission accuracy at many other MAOs. Even though the OIG audits are not methodologically the same as traditional RADV audits (of which CMS has not finalized a single RADV audit since 2007), OIG risk adjustment audits are nonetheless audits, and each and every one has come to the same conclusion- “[the MAO] did not submit some diagnosis codes to CMS for use in the risk adjustment program in accordance with Federal requirements.”  For more information from the New York Times,  see https://www.nytimes.com/2022/10/08/upshot/medicare-advantage-fraud-allegations.html.

Although CMS has been dithering on the question of how RADV audits should be finalized since issuing a Notice of Proposed Rulemaking on November 1, 2018 (83 FR 54982), it now appears that CMS will issue its final RADV rules on or before February 1, 2023.