In the world of Medicare Advantage, Risk Adjustment Data Validation audits are a hot topic! There are plenty of myths floating around RADV audits that can trip up even the most well-meaning organizations. These misconceptions can lead to decisions that backfire when it comes to audit outcomes. Let’s dive into some of the most common myths and set the record straight!
Myth 1: “Only large MA plans get selected for a RADV audit”
The myth: Smaller MAOs assume they fly under the radar of CMS, believing that RADV audits primarily target larger, high-profile MAOs.
The fact: RADV audits are designed to ensure program integrity across all MAO plans, regardless of their size. CMS uses data-driven methods, like improper payment prediction models, to identify audit targets. Consequently, any plan predicted to have significant reductions in their risk score due to a RADV audit, can be flagged for scrutiny.
Why it matters: Overconfidence can leave smaller plans vulnerable to unexpected audits and potential extrapolated repayment penalties.
Myth 2: “If we are selected for an audit, we’ll have time to prepare”
The myth: MAOs believe they can quickly gear up for a RADV audit if they are selected.
The fact: RADV audits come with tight deadlines. Scrambling to gather records, building teams, and finding the right tools after receiving an audit notice often results in errors and delays that could have been avoided with proactive preparation.
Why it matters: The sooner MAOs submit medical records to CMS, the quicker they will receive feedback. Having your team, processes, and tools ready beforehand improves chances of success.
Myth 3: “We don’t need coders to do this work”
The myth: Some MAOs believe they can manage RADV audit documentation review without needing the specialized skills of experienced coders.
The fact: While basic understanding of the audit process might suffice for some tasks, RADV audits require the specialized skills of trained coders. Coding professionals possess the expertise needed to interpret complex medical records accurately and ensure compliance with coding guidelines.
Why it matters: Leveraging the knowledge of skilled coders is crucial to minimize errors and avoid compliance issues. Their involvement ensures that submissions are accurate, significantly reducing the risk of penalties from RADV audits.
Myth 4: “We only need to submit the records where the HCC originated”
The myth: Some MAOs believe they can limit their submissions to only the specific records where Hierarchical Condition Categories (HCCs) originated.
The fact: RADV audits require a comprehensive review of all available medical records to validate submitted diagnoses. MAOs can submit any acceptable record that supports the HCC within the audit year, and often better examples of the HCC can be found in records where the HCC was not originally billed.
Why it matters: MAOs can review and submit any acceptable record that supports the HCC, not just those where the HCC originated. This ensures they are not missing out on better, more accurate documentation, thereby reducing repayment penalties and improving audit results.
Myth 5: “There’s nothing we can do to reduce repayment penalties”
The myth: Some MAOs mistakenly believe that uncovering additional HCCs in submitted records, even if they aren’t part of the audit, doesn't help reduce repayment penalties.
The fact: If an MAO identifies valid diagnoses that support HCCs within the audit sample, they can offset overpayment amounts. However, it’s important to note that additional HCCs can only mitigate penalties and cannot result in extra payments beyond the audit period.
Why it matters: By ensuring a thorough review of all available records and identifying additional diagnoses that support HCCs, MAOs can offset overpayment amounts.
Myth 6: “There is no technology to help my team navigate this audit, so we’ll be using spreadsheets”
The myth: Some MAOs assume that managing a RADV audit is a manual process reliant on spreadsheets and disparate systems.
The fact: Advanced technology specifically designed to support RADV audits is now available. This revolutionary project management tool is crafted to optimize health plans' responses to regulatory audits. Fit for purpose software efficiently and accurately captures all HCCs from audited medical records and recommends the best charts to submit for the highest validation rates, significantly mitigating the impact of repayment penalties.
Why it matters: Leveraging technology not only improves efficiency but also ensures a higher degree of accuracy and compliance, enabling MAOs to meet audit requirements with confidence.
From myths to mastery: Equip your team for RADV success
Dispelling myths turns RADV audits from daunting challenges into manageable tasks. With the right tools, RADV audits shift from overwhelming to achievable, empowering your team for success. Advanced tools can streamline processes, improve accuracy, and empower your team to handle audits with confidence. Leveraging these innovations will be crucial for organizations to achieve the best audit outcomes.
To deepen your understanding and prepare your team for success, we invite you to join our webinar, Master the Maze of Medicare Advantage RADV Audits. Gain valuable insights and strategies as we review the audit process, key dates, and best practices. Or, connect with us to learn more about tools to prepare your team for RADV audits.
About the authors
Melissa James
Melissa James, CPC, CPMA, CRC, risk adjustment SME, senior consultant, Wolters Kluwer, Health Language, supports the company's Health Language solutions with content maintenance. She has more than 20 years of health care experience in coding, risk adjustment, billing, physician and coder education, accounts receivable management, regulatory and compliance, and consulting. She received her associate degree from Pueblo Community College.
Kimberly Rykaczewski
Kimberly Rykaczewski, R.N., BSN, CPC, CRC, clinical content management–medical terminology & risk adjustment, Wolters Kluwer, Health Language, supports the company’s Health Language medical terminology solutions focusing on the standardization of medical terminologies to expedite data normalization to enhance health care system interoperability. Rykaczewski manages a team focused on providing data quality solutions by monitoring regulatory coding content and providing diagnostic and procedural mapping sets.
She has over 20 years of health care experience in the areas of nursing, case management, utilization review, overpayment recovery, vendor management, coding and billing, risk adjustment, and regulatory compliance. One of the biggest rewards of her profession is bringing providers and payors together to achieve regulatory and coding compliance. Rykaczewski holds a Bachelors of Science in Nursing and is an AAPC-certified professional and risk adjustment coder.
