Crisis Management for a Conflict with North Korea

Crowell & Moring LLP | English | AcademicThink | Nov. 28, 2025 | UndeterminedLegal Exposure

On November 21, 2025, the Centers for Medicare & Medicaid Services (CMS) appealed the Northern District of Texas’ ruling in Humana Inc. et al. v. Becerra et al. This ruling had vacated CMS’s 2023 Final Rule, which eliminated the use of the Fee-for-Service (FFS) adjuster in Risk Adjustment Data Validation (RADV) audits and incorporated extrapolation starting with Payment Year (PY) 2018. The court determined CMS failed to meet the Administrative Procedure Act’s (APA) notice-and-comment requirements due to a change in the agency’s justification between the Proposed and Final Rules without adequate public notice.

The appeal notice did not specify CMS’s arguments, but the government is expected to file a detailed brief in early 2026. The appeal comes just before the November 24, 2025 deadline for submitting the second batch of RADV audits for PY 2019. Audits for PY 2020 and later have not formally begun, leaving health plans uncertain about CMS’s approach for 2026. CMS had previously announced an aggressive plan in May 2025 to intensify Medicare Advantage oversight, aiming to complete audits for PY 2018 through PY 2024 by early 2026, though staffing and procedural challenges may affect this timeline.

In parallel, the Health and Human Services’ Office of Inspector General (HHS-OIG) is conducting a separate audit, initiated in August 2025, to assess Medicare Advantage organizations' compliance with federal requirements on diagnosis code submissions, with results expected in 2027. Given ongoing developments, CMS’s final RADV audit strategy remains uncertain, and health plans are advised to monitor updates carefully. Crowell & Moring LLP continues to provide support and counsel for Medicare Advantage organizations throughout the RADV audit process.