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Medicare Advantage Payment Validation

CMS verifies the accuracy of Medicare Advantage payments by conducting Risk Adjustment Data Validation (RADV) audits.

Medicare Advantage Payments

The Centers for Medicare & Medicaid Services (CMS) pays Medicare Advantage plans a monthly, per-person, fixed rate, also known as a capitated payment, to deliver care to Medicare beneficiaries. This capitated payment is based on county level average Fee-For-Service (FFS) Medicare cost and is then risk adjusted for each individual to account for differences in health, demographics, and other risk factors. Risk scores are subsequently reduced by the “coding intensity adjustment” applied annually, across-the-board to reduce the risk scores to account for the difference in coding patterns between FFS Medicare and Medicare Advantage.