News Update on CMS RADV Findings

Center for Public Integrity Publishes Latest News on RADV Audits

Fred Schulte published the most recent article in his continuing series regarding the Medicare Advantage risk adjustment data validation audits.  Check out the article:  Based upon the results from a Freedom of Information Act filing and subsequent court order, it appears that CMS has released some information that previously was unavailable to the public regarding four healthplan audits, in addition to one recently released regarding PacifiCare of Washington. 

The key issue here is the CMS findings regarding the failure of chart audits to validate the diagnosis originally submitted to CMS in RAPS data. However, much of the nitty gritty information such as the specific diagnoses was redacted and not visible for review. What are the detailed findings?  Is there a normative benchmark against which the plans are compared for extrapolation purposes?  How are things such as Past Medical History treated for risk adjustment purposes, and how does this contrast with Medicare FFS billing rules?  These and many more likely questions are not addressed, it appears.  Nor is the ultimate question:  what is truly considered "upcoding" under CMS RADV purposes and what is not? 

The argument presented in the previous articles by Mr. Schulte is that the regulations and the law call for first-dollar extrapolation on every unsubstantiated diagnosis / HCC, not utilizing some kind of benchmark error rate.  

Stay tuned.  This promises to be very interesting, to say the least. 



Tags: RADV audits

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