Data submissions for risk adjustment have been around for many years. So too have audits of those submissions. For example, the Centers for Medicare & Medicaid Services (CMS) selects a certain number of Medicare Advantage (MA) and Medicare Shared Savings Program (MSSP) ACO contracts to undergo Risk Adjustment Data Validation (RADV) audits. RADV audits have two main purposes: one, to ensure contracts have met CMS’ submission requirements, and two, to validate HCC codes by ensuring the submitted diagnoses are supported by medical documentation. A mistake in either one of these areas can have severe financial consequences for insurers, so there’s one key question you want to ask yourself: Are you prepared for what the RADV has in store for you?
Coming Soon: An Increase in RADV Audits
In 2014, the U.S. Government Accountability Office (GAO) conducted a study of CMS’ efforts to address improper payments in the MA program, which were estimated at about $14.1 billion in 2013. In April 2016, GAO released its report, called “Fundamental Improvements Needed in CMS’s Effort to Recover Substantial Amounts of Improper Payments,” outlining the findings. The report reveals the need for improvements to strengthen the quality outcomes of RADV audits as related to improper payment recoveries. It recommends five ways for CMS to improve its selection and payment recovery processes, and since the Department of Health & Human Services (HHS) agrees with the recommendations, there’s a good chance that not only will CMS start auditing more contracts, but the audits will also have an even more intense focus on payment recovery.
To mitigate the potentially costly impact of an RADV audit, my advice for MA health plans that have coders abstracting from medical records is simple: Make sure they are properly trained and they know why they are coding the way they do.
How to Be RADV Audit Ready
Most of the common mistakes coders make in the abstraction process happen because they don’t know all the idiosyncrasies that apply to the abstraction. Auditors heavily scrutinize coding rules; health plans can better ensure compliant coding by providing coders with the tools they need to code accurately and efficiently and by making sure their coders understand and master all relevant HCC coding guidelines: