Next-generation technology supports Medicare Advantage Organizations (MAOs) as they navigate regulatory audits

Traditional, manual auditing processes that utilize spreadsheets or homegrown databases are prone to errors, data loss, or even data corruption. With thousands of lines of coding data, the manual analysis and selection of records for a risk adjustment audit is nearly impossible.

The Health Language Coder Workbench Regulatory Audit Module integrates clinically-trained AI technology to ensure that every chart submitted is optimized for compliance and accuracy, with an average of 5-7% additional codes identified.

Embedded logic enables you to prioritize charts that need review, improving the coder efficiency by 25%+ and ensuring the best dates of service are submitted to ensure the highest validation rates to mitigate the impact of extrapolated repayment policies.

Leave manual audit workflows and inefficiencies in the past. Request a demo to see how to take your audit processes from a regulatory requirement to a strategic advantage.

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CMS estimates that 9.5% of payments to MA Organizations are improper, mainly due to unsupported, submitted diagnoses.

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The Health Language Regulatory Audit Module

The Health Language Coder Workbench Regulatory Audit Module is a revolutionary project management tool designed to optimize the health plans' response to regulatory audits. Our clinically- trained AI efficiently and accurately captures all HCCs from audited medical records and recommends the best charts to submit for the highest validation rates to mitigate the impact of repayment penalties. 

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Understanding Risk Adjustment Audits: OIG and RADV  

RADV and OIG audits are not merely regulatory hurdles but opportunities to fortify the foundations of risk adjustment compliance. 

Office of Inspector General (OIG) audits 
The Office of the Inspector General (OIG) provides oversight of the programs and operations of the Department of Health & Human Services (HHS). As part of its mission to protect the integrity of HHS programs, and the health and welfare of the people served through these programs, they conduct audits of health plans, validating risk-adjusted payments made by CMS. Recently, the OIG has made its intentions clear through its work plan, signaling a crackdown on auditing MAOs to identify fraud, waste, and abuse that could result in overpayments in an effort to protect taxpayer dollars.​
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Preparing for a risk adjustment audit: Tips from the OIG work plan 
Risk Adjustment Data Validation (RADV) audits 

The RADV Final Rule published January 30, 2023, was a pivotal moment for Medicare Advantage Organizations, shaping their approach to risk adjustment audits. CMS announced that they were no longer going to apply a Fee For Service (FFS) adjustment factor to RADV audits and beginning in PY2018 extrapolation will apply to audit findings. Health plans now more than ever need to have the highest validation rates on RADV audits to reduce the financial implications.

 

The onus is on MA plans to invest in technologies that streamline chart retrieval, accurately prioritize charts for review, and ensure all diagnoses are captured and documented according to Official Guidelines for Coding and Reporting.  

Seven key strategies for a successful RADV Audit

Webinars to help you prepare for an OIG or RADV audit 

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How your risk adjustment team can improve compliance 
Watch this webinar on improving risk adjustment compliance and preparing for OIG audits. Learn about avoidable coding errors, financial impacts, and available tools to avoid penalties. 
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It’s not IF, it’s WHEN: Best practices to survive a RADV audit 
Is your organization ready for the next RADV audit? In this webinar conducted in partnership with RISE, our risk adjustment experts discuss best practices, strategies, and tips for audit preparedness. 
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Latest resources on risk adjustment compliance 

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How CMS-HCC v28 will impact risk adjustment factor (RAF) scores 
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Are your risk adjustment programs compliant? 
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Understanding the RADV final rule from a medical coder 
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