RADV Audit Services for Compliance with CMS Contract Requirements

by | Published on Jul 11, 2016 | Medical Coding

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The Centers for Medicare and Medicaid (CMS) conduct Risk Adjustment Data Validation (RADV) audits to recover improper payments under Medicare Part C or Medicare Advantage (MA) plans. In risk adjustment or Hierarchical Condition Categories (HCCs), the focus is on rewarding better outcomes in the care provided for sicker patients. More and more insurance companies are relying on professional RADV audit services to ensure that their MA plans meet CMS contract requirements.

CMS reviews medical record documentation provided by each audited MA organization to determine a record’s suitability for Risk Adjustment Data Validation (RADV). According to the 2015 U.S. Department of Health & Human Services (HHS) Agency Financial Report, up to 75% of estimated overpayments to Medicare Advantage (MA) plans were due to shortcomings in provider documentation which is needed to support the patient’s risk score through the reported diagnosis codes.

Ensure Medical Documentation to Support Risk Scores with RADV Audit Services

The severity of illness of MA plan members is measured by the diagnosis codes that are submitted on claims received from their physicians for office visits.

Outsourcing companies that provide services to help MA plan providers prepare for-RADV audits will review medical records submitted with claims to ensure that they have the right ICD-10 codes. Services provided will cover checks for the following:

  • The diagnosis is clearly defined and supports the requested hierarchical condition category (HCC)
  • Conditions that warrant hospitalization are supported by an inpatient record, a stand-alone inpatient consultation record, or a stand-alone discharge summary
  • Records from specialists treating the condition
  • In the case of cancer diagnosis, ensure documentation and codes that indicate current treatment of the condition
  • Documentation that includes all the problems assessed during the visit with appropriate codes
  • Identification of incorrect or invalid ICD-10-CM codes and missed or unreported ICD-10-CM data.
  • Ensure that inpatient records contain an admission and discharge date as well as include signed discharge summaries.
  • Establish the steps needed to resolve any uncovered issues.

Stay Confident with RADV Mock Audit Services

The practice of upcoding patients’ diagnoses for conditions they do not have in order to get larger Medicare payments continues to be a looming problem, according to recent reports. The government’s PaymentAccuracy.gov website reports that duplicate payments and inaccurate payments to eligible beneficiaries cost the federal government $137 billion in 2015, with Medicare and Medicaid payments accounting for major portion of this.

CMS has roped in Recovery Audit Contractors (RA auditors to identify and correct overpayments and underpayments in Medicare Part C. Where medical record documentation is missing, a payment error would be identified and plans would be have to pay back to CMS. The Office of the Inspector General (OIG) is taking steps to deal with over-coding of HCCs.

By relying on RADV audit services to ensure accuracy of their providers’ coding and documentation to meet CMS contract, payers can stay confident that their plans are ready for the federal audit and also ensure accurate reimbursement.

Meghann Drella

Meghann Drella possesses a profound understanding of ICD-10-CM and CPT requirements and procedures, actively participating in continuing education to stay abreast of any industry changes.

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