Risk adjustment data validation

(a) Risk adjustment data validation reforms Section 1853(a)(1)(C) of the Social Security Act is amended by adding at the end the following new paragraph: (7) Improving timeliness of RADV audits and appeals For plan years beginning on or after January 1, 2028, the following requirements shall apply with respect to the Medicare Advantage Risk Adjustment Data Validation Program: (A) Contract-level audits The Secretary shall complete contract-level audits within one year. (B) Medical record reviews The Secretary shall complete RADV medical record reviews within 60 days. (C) Deadline for completion of stages 1 and 2 of appeals (i) Stage 1 The reconsideration stage described in section 422.311(c)(6) of title 42, Code of Federal Regulations (or a successor regulation), shall be completed within 90 days. (ii) Stage 2 The hearing stage described in section 422.311(c)(7) of title 42, Code of Federal Regulations (or a successor regulation), shall be completed within 90 days. (D) User fee The Secretary shall reduce the payments to Medicare Advantage organizations under section 1853 by 0.02 percent for the purpose of carrying out Risk Adjustment Data Validation audits. (E) Limitation on review There shall be no judicial review under section 1869, section 1878, or otherwise of any determination of the Administrator of the Centers for Medicare and Medicaid Services under the Risk Adjustment Data Validation audit program. (F) Authority to extrapolate The Secretary may extrapolate the results of audited samples to the general Medicare Advantage population and retroactively, as the Secretary determines appropriate.. (b) Enhancing audit process Section 1853(a)(1)(C) of the Social Security Act, as amended by subsection (a), is amended by adding at the end the following new paragraph: (8) Identification and recoupment of overpayments (A) In general The Secretary shall enter into contracts with one or more recovery audit contractors under section 1893(h) for the identification and recoupment of overpayments, including penalties as defined under subparagraph (B), with respect to items and services for which payment is made under this part. (B) Penalty With respect to any overpayment identified under subparagraph (A), the Secretary shall provide for the imposition a penalty in an amount equal to the total amount of overpayment and the rate of interest as defined under section 405.378(d) of title 42, Code of Federal Regulations (or a successor regulation). (C) Contingency fees The Secretary may provide contingency fees to recovery audit contractors in an amount equal to no more than 20 percent of recouped overpayments made by such contractor..