Risk adjustment audit season is upon us. Some health plans are already in the thick of retrieving charts and starting reviews. Whether it’s a Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) audit or a Health and Human Services (HHS)-RADV, one thing is true: being prepared is a must!
RADV is the process utilized by the Centers for Medicare & Medicaid Services (CMS) to verify that Hierarchical Condition Category (HCC) diagnoses submitted through Risk Adjustment Processing System (RAPS), Encounter Data Processing System (EDPS), and the EDGE Server are adequately supported by a medical record for that member. RADV was originally put into place as a validation process to ensure complete and accurate data is being submitted, to help reduce the Medicare Part C error rate, and to comply with the Improper Payments Elimination and Recovery Act (IPERA – Public Law 111-204) of 2010. Since then, risk adjustment and the foundational principles of RADV have been adapted by commercial qualified health plans but carry vastly different processes for health plans to adhere to.
Organizations that have commercial plans know HHS-RADVs will be conducted annually, and MA RADV is by selection only. Given that MA RADV is by selection only, most health plans aren’t fully prepared if they were to be selected. Be sure to keep in mind there is a high likelihood the MA RADV will evolve over the coming years to include more auditing of health plans, if not all of them, on an annual basis. Preparedness for a RADV does not begin at the time of the audit or upon being selected but rather is a continuous process that should be conducted year-round.
There are many operational processes throughout a health plan that are implemented to ensure information submitted to CMS is complete and accurate. All of the retroactive, prospective, and validation processes established have all been put into place to lower your risk during a RADV. Having operational processes in place is only part of the equation to being fully prepared for a RADV. The second portion is to ensure your organization has a game plan for accomplishing each phase of the RADV successfully and within the allotted time. This is often referred to as a “RADV Playbook.”
A RADV Playbook has three primary components that establish the precedence around each one of the following categories:
- Clear Responsibilities – Understand who needs to be involved during and after the audit and what their key responsibilities will be.
- Communication and Outreach – Establish the timing around outreach, medical records review, and triaging issues.
- Operational Logistics – Identify what is needed in order to holistically complete the RADV. This is where understanding any IT limitations within your company are helpful and whether you will be utilizing vendors to assist.
The RADV process can be fast and furious with many moving pieces running in parallel. If you have properly prepared and have a solid RADV Playbook, you will surely survive the audit and put the last piece of the puzzle into place to see the final view of that payment year. For assistance with pre- or post-RADV audit support, contact me at firstname.lastname@example.org.
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