{"abstract":"This final rule announces certain policies to improve program integrity and payment accuracy in the Medicare Advantage (MA) program. The purpose of this final rule is to outline our audit methodology and related policies for the contract-level MA Risk Adjustment Data Validation (RADV) program. Specifically, this final rule codifies in regulation that, as part of the RADV audit methodology, CMS will extrapolate RADV audit findings beginning with payment year (PY) 2018 and will not extrapolate RADV audit findings for PYs 2011 through 2017. We are also finalizing a policy whereby CMS will not apply an adjustment factor (known as a Fee-For-Service (FFS) Adjuster) in RADV audits. We are also codifying in regulation the requirement that MA organizations (MAOs) remit improper payments identified during RADV audits in a manner specified by CMS.","action":"Final rule.","agencies":[{"raw_name":"DEPARTMENT OF HEALTH AND HUMAN SERVICES","name":"Health and Human Services Department","id":221,"url":"https://www.federalregister.gov/agencies/health-and-human-services-department","json_url":"https://www.federalregister.gov/api/v1/agencies/221","parent_id":null,"slug":"health-and-human-services-department"},{"raw_name":"Centers for Medicare & Medicaid Services","name":"Centers for Medicare & Medicaid Services","id":45,"url":"https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services","json_url":"https://www.federalregister.gov/api/v1/agencies/45","parent_id":221,"slug":"centers-for-medicare-medicaid-services"}],"body_html_url":"https://www.federalregister.gov/documents/full_text/html/2023/02/01/2023-01942.html","cfr_references":[{"chapter":null,"citation_url":null,"part":422,"title":42}],"citation":"88 FR 6643","comment_url":null,"comments_close_on":null,"correction_of":null,"corrections":[],"dates":"This final rule is effective on April 3, 2023.","disposition_notes":null,"docket_ids":["CMS-4185-F2"],"dockets":[{"supporting_documents":[],"agency_name":"CMS","documents":[{"comment_count":null,"comment_start_date":null,"updated_at":"2023-03-15T15:56:37.526-04:00","comment_url":"https://www.regulations.gov/commenton/CMS-2018-0133-0271","allow_late_comments":null,"id":"CMS-2018-0133-0271","comment_end_date":null,"regulations_dot_gov_open_for_comment":false}],"supporting_documents_count":0,"id":"CMS-2018-0133","title":"Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug Benefit, and Medicaid Managed Care Programs for Contract Year 2020 CMS-4185-P"}],"document_number":"2023-01942","effective_on":"2023-04-03","end_page":6665,"executive_order_notes":null,"executive_order_number":null,"explanation":null,"full_text_xml_url":"https://www.federalregister.gov/documents/full_text/xml/2023/02/01/2023-01942.xml","html_url":"https://www.federalregister.gov/documents/2023/02/01/2023-01942/medicare-and-medicaid-programs-policy-and-technical-changes-to-the-medicare-advantage-medicare","images":{},"images_metadata":{},"json_url":"https://www.federalregister.gov/api/v1/documents/2023-01942?publication_date=2023-02-01","mods_url":"https://www.govinfo.gov/metadata/granule/FR-2023-02-01/2023-01942/mods.xml","not_received_for_publication":null,"page_length":23,"page_views":{"count":15705,"last_updated":"2026-04-09 06:15:03 -0400"},"pdf_url":"https://www.govinfo.gov/content/pkg/FR-2023-02-01/pdf/2023-01942.pdf","presidential_document_number":null,"proclamation_number":null,"public_inspection_pdf_url":"https://public-inspection.federalregister.gov/2023-01942.pdf?1675113322","publication_date":"2023-02-01","raw_text_url":"https://www.federalregister.gov/documents/full_text/text/2023/02/01/2023-01942.txt","regulation_id_number_info":{"0938-AT59":{"issue":"202210","html_url":"https://www.federalregister.gov/regulations/0938-AT59/policy-and-technical-changes-to-the-medicare-advantage-and-the-medicare-prescription-drug-benefit-pr","title":"Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs for Contract Year 2020; Risk Adjustment Data Validation (CMS-4185)","xml_url":"http://www.reginfo.gov/public/do/eAgendaViewRule?pubId=202210&RIN=0938-AT59&operation=OPERATION_EXPORT_XML","priority_category":"Economically Significant"}},"regulation_id_numbers":["0938-AT59"],"regulations_dot_gov_info":{"supporting_documents":[],"regulatory_plan":{"html_url":"https://www.federalregister.gov/regulations/0938-AT59/policy-and-technical-changes-to-the-medicare-advantage-and-the-medicare-prescription-drug-benefit-pr","title":"Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs for Contract Year 2020; Risk Adjustment Data Validation (CMS-4185)"},"comments_count":0,"agency_id":"CMS","comments_url":"https://www.regulations.gov/docketBrowser?rpp=50&so=DESC&sb=postedDate&po=0&dct=PS&D=CMS-2018-0133","supporting_documents_count":0,"docket_id":"CMS-2018-0133","document_id":"CMS-2018-0133-0271","regulation_id_number":"0938-AT59","title":"Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug Benefit, and Medicaid Managed Care Programs for Contract Year 2020 CMS-4185-P","checked_regulationsdotgov_at":"2023-03-16T18:00:17Z"},"regulations_dot_gov_url":null,"significant":true,"signing_date":null,"start_page":6643,"subtype":null,"title":"Medicare and Medicaid Programs; Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug Benefit, Program of All-Inclusive Care for the Elderly (PACE), Medicaid Fee-For-Service, and Medicaid Managed Care Programs for Years 2020 and 2021","toc_doc":"Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug Benefit, Program of All-Inclusive Care for the Elderly, etc.","toc_subject":"Medicare and Medicaid Programs:\n","topics":["Health facilities","Health maintenance organizations (HMO)","Medicare","Penalties"],"type":"Rule","volume":88}