Navigating the evolving landscape of RADV audits and risk adjustment compliance

Medicare Advantage Organizations (MAOs) are under increasing scrutiny with the expansion of Risk Adjustment Data Validation (RADV) audits by the Centers for Medicare & Medicaid Services (CMS). Preparing for RADV compliance has become more critical than ever, as audits now involve managing all eligible contracts, handling variable sample sizes, and addressing the implications of extrapolated findings. Maintaining year-round data accuracy, not just during audit cycles, is key to staying ahead.

For PY2020 audits and beyond: Your partner in RADV compliance

Unsure if your team is ready to take on a RADV audit? Our experts are here to help you prepare for the upcoming Payment Year 2020 audits and establish a sustainable compliance framework for the future. Based on their decades of hands-on experience supporting MAO risk adjustment programs and managing RADV audits, we've created the first risk adjustment tool built specifically to support risk adjustment audit workflows. With AI-powered technology, you can streamline your audit workflows, enhance data accuracy, and mitigate financial risks.

Improve chart review efficiency by 25% 

Uncover 10% more higher-value HCCs 

Reduce repayment liabilities by 50% 

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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

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. 
Watch The Webinar

Master the RADV audit process with proven strategies 

In this webinar, risk adjustment experts at Lumeris share their proven strategies to navigate the RADV audit process with confidence from preparation through submission.
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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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African man working at office computer.
Understanding the RADV final rule from a medical coder 
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