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On Thursday, the Centers for Medicare & Medicaid Services (CMS) announced a significant expansion of its risk adjustment data validation (RADV) audits for Medicare Advantage (MA) plans. The agency revealed its intention to complete audits for payment years 2018 through 2024 by early 2026. To accomplish this, CMS plans to utilize advanced technology for more efficient medical record reviews and will boost its medical coder staff from 40 to 2,000. The volume of audits will also see a substantial increase, with all approximately 550 MA plans to be audited annually, a sharp rise from the 60 plans audited previously.
The expansion means that each MA plan will now be subject to the review of 35 to 200 records per year, compared to 35 in past audits. While the financial impact of the expanded audits is yet to be fully determined, CMS has not provided an impact analysis. However, if extrapolation from the 2023 RADV final rule is permitted, CMS could potentially recover between $10 million and $16 million per audit per plan. This could amount to an annual recovery of $5 billion to $9 billion, representing 1-2% of total MA payments.
Following the announcement, MA stocks experienced a downturn, with shares trading down between 3-5% after market hours on Thursday. According to InvestingPro analysis, CVS is currently trading below its Fair Value, with a P/E ratio of 14.86 and maintaining a solid 4.28% dividend yield. Investors are apprehensive about the potential funding pressures and a less accommodating regulatory environment under the current administration. MA plans, theoretically, have the flexibility to adjust benefits in response to changes in funding levels, which could mitigate the potential impact. Nevertheless, MA plans have struggled with adapting to higher utilization throughout 2023-2024 and the phase-in of v28 affecting 2024-2026, leading to all large MA plans currently earning below their target margins.
KeyBanc maintains a Sector Weight (SW) stance on Humana Inc . (NYSE:HUM) and Alignment Healthcare (NASDAQ:ALHC), and an Overweight (OW) position on UnitedHealth Group (NYSE:UNH). For deeper insights into healthcare sector valuations and comprehensive analysis, including 8 additional ProTips for CVS, check out the detailed Pro Research Report available on InvestingPro. Despite the current challenges, KeyBanc suggests that the issues negatively impacting the sector in 2025 should be resolvable by 2026. However, they anticipate that clarity on the 2026 earnings recovery for these companies will likely not emerge until late 2025.
In other recent news, CVS Health Corp (NYSE:CVS). has reported strong financial performance in the first quarter of 2025, with earnings per share (EPS) of $2.25, significantly surpassing the forecast of $1.64. The company’s revenue reached nearly $95 billion, marking a 7% year-over-year increase. CVS Health has also raised its full-year EPS guidance to a range of $6.00 to $6.20. In a strategic move, CVS has proposed acquiring a number of Rite Aid Corp (NYSE:US90274J5618=UBSS). stores and patient data in the Pacific Northwest, as Rite Aid winds down operations following its second bankruptcy declaration. Analysts at JPMorgan have responded positively, raising CVS’s stock target to $86 and maintaining an Overweight rating, citing the company’s better-than-expected earnings and strategic initiatives. Meanwhile, Cantor Fitzgerald has reaffirmed its Overweight rating on CVS, highlighting the company’s strategic direction and potential for growth. Additionally, CVS Caremark has partnered with Novo Nordisk (NYSE:NVO) to make Wegovy the preferred weight-loss drug for its members, enhancing access to the medication at a more affordable price. These developments reflect CVS Health’s ongoing efforts to expand its market presence and improve its service offerings.
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