The Office of Inspector General (OIG) recently released a report estimating that CMS may have overpaid Medicare Advantage Organizations approximately $462 million in 2021 based on unsupported acute stroke diagnoses. For those working in Medicare Advantage risk adjustment, the findings themselves should not come as a surprise.

CMS released the PY2020 Medicare Advantage RADV audit notices on Friday—and this round is significant. A total of 471 Medicare Advantage contracts are now under review, making it the largest audit cohort to date.

CMS recently released an updated Risk Adjustment Data Validation (RADV) Questions & Answers document along with a schedule outlining when upcoming Medicare Advantage RADV audits are expected to begin by payment year. While the release does not introduce major policy changes, it does provide something many organizations have been looking for, which is greater transparency into how CMS intends to sequence future RADV audits.

On Monday, the Centers for Medicare & Medicaid Services released the Calendar Year (CY) 2027 Advance Notice for the Medicare Advantage (MA) and Part D programs. At more than 160 pages, the document pairs a modest projected payment increase with some of the most consequential refinements to MA risk adjustment in recent years.

Medicare Advantage & Part D Advance Notice

On Friday, June 13th, CMS officially initiated PY2019 Medicare Advantage RADV audits , marking a significant escalation in oversight and...

Insights from the 2025 RISE Risk Adjustment Forum As CMS ramps up oversight and plans prepare for V28 and RADV expansion, the 2025 RISE Risk Adjustment Forum highlighted what’s top of mind for risk adjustment leaders across the country. The message was clear: success in 2025 depends on smarter strategy, cross-functional coordination, and proactive compliance. Here are five key takeaways to guide your risk adjustment efforts in the year ahead: 1. Internal Auditing Is No Longer

CMS has just announced a major expansion of its audit program for Medicare Advantage (MA) plans—shifting from sampling a few contracts to auditing all eligible plans each year. The Trump Administration aims to complete all outstanding RADV audits for PY 2018–2024 by early 2026. This move brings unprecedented scrutiny, larger record volumes, and significant extrapolation risk. At Rebellis Group, we’re already helping plans prepare for this new era of oversight—and we’re ready

CMS’s CY 2025 Final Rule: A Quick Summary

The Centers for Medicare and Medicaid Services (CMS) published the Calendar Year (CY) 2025 Medicare Advantage (MA) Capitation Rates and...

New Guidance Released on Encounter Data Submission of Supplemental Benefits

Risk Adjustment: Is Your Organization Ready For The Transition from V24 to V28?

A bipartisan bill has recently been introduced by Senators Bill Cassidy, MD (R-LA) and Jeff Merkley (D-OR) aimed at addressing risk...

On March 31, 2023, the Centers for Medicare & Medicaid Services (CMS) issued its Announcement of Calendar Year (CY) 2024 Medicare...

On January 30th, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS),...

Here’s a big thing that Betsy Seals makes clear in this show: Big companies can be successful in Medicare Advantage (MA)—and I mean...

The Centers for Medicare and Medicaid Services (CMS) published the Announcement of Calendar Year (CY) 2023 Medicare Advantage (MA)...

Co-Authored by Betsy Seals, CEO and Martha Goodlin, RN Over the past several years, we have seen an increase in CMS, OIG, and DOJ activity around recouping “improper” payments in the Medicare Program. With the new administration, the focus on identifying and recouping improper payments is almost palpable. Most recently, on August 30th, the DOJ and Sutter Health settled on Sutter paying $90 Million to Settle False Claims Act Allegations of Mischarging the Medicare Advantage Pr