While fraudulent intentions are not the norm, no MAO executives will be sleeping easy. Even those MAOs that have made efforts with compliance programs to accurately capture their members' health statuses are still found to be lacking in major areas according to previous OIG report findings.
Impacts of the RADV final rule
The final rule was released on January 30, 2023. It addressed three main points: fee for service adjuster (FFSA), extrapolation, and retroactivity. This ruling is a pivotal moment in the risk adjustment space and will impact every MAO.
To summarize the impact of these key components:
- Fee for Service Error Rate Adjustment - CMS will not apply a FFS adjustment factor in RADV audits.
- Extrapolation and retroactivity - CMS will not extrapolate RADV audit findings for payment years (PY) 2011-2017 but will begin extrapolation with the PY 2018 RADV Audit. It’s estimated that insurers will get to keep $2 billion by only doing extrapolation from 2018 and beyond.
As a former RADV coding auditor for a major health plan, I've performed the RADV audits, I've reviewed and trended the results from CMS, and I've read and analyzed the OIG reports. MAOs need to be hyper-focused on avoiding large repayment amounts by increasing their validation rates in these regulatory audits. This is accomplished by ensuring better accuracy. While that sounds very simplistic there are several key components that feed into this accuracy of coding.
Four keys to improving the accuracy of risk adjustment coding
1. Provider documentation
Providers need education on documentation. But they can't do this alone. While they shouldn't be experts in coding rules and guidelines, they should have basic knowledge of how coding works. They should have an understanding of the nomenclature in the ICD-10 classification.
One way to address this is to identify validation rates on a provider basis. Targeted education based on this feedback from clinical documentation (CDI) professionals, as these professionals bridge the information gap between provider and coder. To sum this up, providers need feedback from MAOs on audit findings if they expect change.