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RISK ADJUSTMENT DATA VALIDATION (RADV)

CMS has started conducting its Risk Adjustment Data Validation (RADV) Audit which will continue till august of this year. So this is the high time you should know in and out of Risk Adjustment Data Validation Audits so to prevent payment of high penalties. Federal laws need Medicare Advantage organizations, their providers, and practitioners to submit medical records for the validation of risk-adjustment data.

The targeted RADV needs Blue Cross and Blue shield of North Carolina to gather medical records for the CMS-selected sample population, whose claims were submitted to CMS for calculations of risk adjustments. When a Blue Cross NC employee contacts you to obtain medical charts, please provide them within a few days of the initial request.

The audit method begins in April, after CMS gives us the sample of members on whom they want the RADV performed. Recent reports from the Government Accountability Office and Department of Health and Human Services Office of the Inspector General raise concerns that CMS is not performing RADV audits quickly enough and urge the Agency to implement a proposal mirrored in an exceedingly CMS Request for data that might incorporate Medicare Recovery Audit Contractors (RACs) into the RADV method and considerably expand the scope and scale of RADV audits.

CMS presently conducts RADV audits on thirty contracts per payment year. Under the audit methodology, the payment error calculated for 201 sampled beneficiaries is extrapolated to the entire contract population.

The Agency is still in the process of conducting the initial rounds of audits—for contract years 2011 and 2012—to which it will apply the current methodology, and has not yet released its methodology for calculating the “Fee-for-Service Adjuster” necessary to account for improper payments in the Medicare fee-for-service program under the current payment system. Expanding RADV audits without first ensuring the audit process is reliable could jeopardize the viability of the Medicare Advantage program, disrupt care for beneficiaries and limit the ability of CMS and plans to incorporate valuable lessons learned from the audit results.

Expanding the amount of RADV audits through the employment of RACs can doubtless increase the burden on physicians and different health care suppliers to seek out, review, and submit medical record documentation substantiating patient diagnoses upwards of six years prior.

In several instances, network suppliers’ contract with varied plans, which means extra audits on these practices would be increased. This increased administrative burden detracts much needed provider resources from care delivery, which could harm beneficiaries.

Join our upcoming webinar to know more about medicare advantage and risk adjustment.

Risk Adjustment Data Validation (RADV): Auditing Target Medicare Advantage Plan

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CMS has started conducting its Risk Adjustment Data Validation (RADV) Audit which will continue till august of this year. So this is the high time you should know in ...
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