Is Your Plan Ready for a RADV Audit?

(3 Minute Read)

HELP YOUR ORGANIZATION BECOME COMPLIANT AND PREPARED WITH MOCK RADV AUDITS.

Each year CMS selects 30 plans for RADV (Risk Adjustment Data Validation) audits to confirm that the documented diagnoses in their member's medical records match the Hierarchical Condition Category (HCC) codes insurers submitted to Medicare for payment.

Medicare Advantage (MA) health plans are reimbursed based on their beneficiaries’ documented chronic conditions. Elevated risk scores can garner higher reimbursements, but overestimating risk scores may result in costly penalties if found during an audit.

Image result for money RADV audits for FY 2018 uncovered an improper payment rate of 8.12%, representing $31.62 billion in improper payments (www.cms.gov). These audits can have serious financial repercussions for plans that are caught unaware with insufficient documentation.

As regulators increase the frequency and scope of Risk Adjustment audits, health plans must engage in a proactive approach to RADV audits. To avoid penalties, MA organizations should reevaluate their risk adjustment practices uncovering problematic processes and gaps.

Mock RADV Audits

The risk is too high to rely on current processes to mitigate the risk of adverse findings from a Medicare RADV audit. Many payer organizations now complete periodic mock RADV audits to help discover where they are at risk. The investments in time and resources to address these issues will improve risk adjustment accuracy and minimize potentially catastrophic financial penalties.

Impresiv Health’s Mock RADV Audit Checklist can help you get started on your journey to better documentation compliance. Based on the checklists used by CMS auditors, Impresiv Health’s tool focuses on the prime areas of noncompliance and coding errors.

Top 10 Medicare Risk Adjustment Coding Errors
(www.aapc.com)

Documentation doesn’t indicate the diagnoses are being evaluated, assessed, addressed, or treated (MEAT).
The record does not contain a legible signature with credentials.
Status of cancer is unclear, or treatment is not documented.
The electronic medical records were unauthenticated (Not electronically signed).
Lack of specificity (e.g., an unspecified arrhythmia is coded rather than the specific type of arrhythmia).
The highest degree of specificity was not assigned to the most precise code to fully explain the narrative description of the symptom or diagnosis in the medical chart.
Chronic conditions, such as diabetes or renal insufficiency, are not documented as being chronic.
The diagnosis code being billed is different than the diagnosis code in the medical record.
A link or cause relationship is missing for a diabetic complication, or there is a failure to report a mandatory manifestation code.
A discrepancy was found between the diagnosis codes being billed versus the actual written description in the medical record. If the record indicates depression, NOS (311 Depressive disorder, not elsewhere classified), but the diagnosis code written on the encounter document is major depression (296.20 Major depressive affective disorder, single episode, unspecified), these codes do not match; they map to a different HCC category. The diagnosis code and the description should mirror each other.

FIND THE RISK ADJUSTMENT SUPPORT YOU NEED

Download Impresiv Health's Free Mock RADV Audit Checklist
Help your organization become compliant and prepared with Impresiv Health's free Mock RADV Audit Checklist.

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