RADV refers to Risk Adjustment Data Validation, which is the process of verifying diagnosis codes submitted for payment with the support of medical record documentation. RADV aims at increasing auditing activity consistent with an emphasis to reduce payment errors. RADV audits ensure that beneficiaries, including those with chronic conditions, are enrolled in plans that will ensure proper reimbursement to meet their individual health needs. At Outsource Strategies International, we can help you become compliant and get RADV audit ready.
The Centers for Medicare and Medicaid Services (CMS) perform RADV audits to validate the accuracy of the HCC (Hierarchical Condition Category) codes submitted by MA (Medicare Advantage) plans for payment. CMS adjusts payments to MA plans based on the health risks of the participants.
Accurate HCC coding is crucial for RADV. To determine enrollee risk scores, CMS uses the diagnosis codes submitted by MA plans for their enrollees’ medical conditions.
To get started with RADV audits, call 1-800-670-2809. Ask for a Free Trial today!
RADV Types and Audits
CMS uses two main RADV types – Random and Targeted RADV. While random CMS RADV uses a selection process in which a Medicare Advantage (MA) plan is randomly selected for an audit, targeted CMS RADV is applied to MA plans that have raised concerns such as a large increase in risk scores.
CMS categorizes the diagnoses into groups of clinically-related conditions called HCCs, and uses the HCCs and demographic characteristics to calculate a risk score for each beneficiary. These risk scores are then used to adjust the monthly capitated payments to Medicare Advantage organizations for the next payment period.
CMS conducts two types of RADV audits:
- Annual national level audits to estimate the national MA improper payment rate
- Contract-level RADV audits to identify and recover improper payments from MA organizations
RADV audits include the preparation phase, the operational phase, the submission phase, and the post RADV activity phase. These audits measure organization-level payment error rates related to risk adjustment data for payment recovery.
The audit process involves obtaining copies of the IP as well as OP physician and hospital records for the members audited. The supplied medical records must be reviewed and the best medical record identified, which must be submitted to CMS.
Our RADV Audit Services
Certified coders at our medical coding company have extensive experience in HCC coding for risk adjustment. They will perform coding so that each beneficiary’s entire risk profile is reflected in the medical record and completely coded in claims and encounter data. They can abstract all HCC codes to support MA plans in completing accurate risk assessment of their membership and submit accurate and complete data before CMS deadlines.
Our mock RADV audit services include:
- Assessment of available data
- Simulated RADV Audits
- MRA/HCC coding with validation for RADV
- Medical record review to validate adherence to RADV documentation requirements
- Plan-specific audit analysis reporting
- Identification of problem areas and solutions
Our RADV audit services are tailored to meet the requirements of each Medicare Advantage Plan. During the mock audit, we also offer plan-specific audit analysis reporting and calculations of potential payment error.
You can also enjoy cost savings of 30-40%. Call us at 1-800-670-2809 to learn more!