About This Project

Prohibit Medicare Advantage plans from conducting, commissioning, or financially benefiting from in-home health assessments and retrospective chart reviews whose primary output is risk-score-increasing diagnoses. Require that all diagnoses used for risk-adjustment purposes be generated by treating providers in the context of actual care delivery — not by insurer-employed or insurer-contracted assessors. Implement full-population RADV audits with extrapolation as CMS proposed in 2023, with annual recoupment of confirmed overpayments. Require MA plans to publicly disclose the percentage of risk-score diagnoses generated through insurer-initiated assessments vs. treating-provider encounters. The transparency alone will compress the most egregious upcoding before the first audit is completed.

Timeline