About This Project

Accelerate and insulate CMS's existing RADV (Risk Adjustment Data Validation) audit authority from annual lobbying cycles by locking in full-population audit methodology through multi-year rulemaking rather than case-by-case administrative discretion. The core problem is not that CMS lacks audit authority — it already has it — but that (1) audit methodology has historically relied on statistical extrapolation from small samples, systematically underestimating true overpayment levels, and (2) each rulemaking cycle re-opens the door to industry lobbying that delays implementation. The fix is procedural: convert the extrapolation methodology into binding regulation and pair it with automatic recoupment triggers that activate without requiring a new discretionary CMS decision each time. Three components: (1) Full-Population Audit Standard — codify in binding rule that RADV audits use full medical record review rather than statistical sampling extrapolation for any diagnosis code flagged as a high-overpayment-risk category. (2) Automatic Recoupment Trigger — once an audit finding is finalized, recoupment begins automatically on a fixed timeline unless the insurer files a specific, evidence-based appeal — removing current de facto discretion CMS officials have to delay enforcement under lobbying pressure. (3) Independent Assessment Firewall — prohibit financial relationships between entities conducting in-home health risk assessments and entities that receive the resulting risk-adjustment payment, closing the root conflict-of-interest identified in the challenge. Political strategy: bundle this with existing bipartisan interest in Medicare fiscal sustainability — MACPAC and MedPAC have both flagged MA overpayment as a top program integrity concern, giving this technical fix bipartisan cover independent of broader healthcare reform fights.

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