GAO: Medicare Advantage: Fundamental Improvements Needed in CMS’s Effort to Recover Substantial Amounts of Improper Payments

CMS conducts two types of risk adjustment data validation (RADV) audits to identify and correct MA improper payments: national RADV activities and contract-level RADV audits. Based on the most recent national audit, which reviewed 2013 payments, CMS released an Medicare Advantage improper payment estimate of 9.5 percent or $14.1 billion. CMS stated it had recovered about $14 million in improper payments from contract-level RADV audits of 2007 payments and may recover additional amounts depending on the adjudication of appeals filed by MA organizations challenging some of the audit findings. Since 2010, CMS has spent about $117 million on both types of audits.