CMS is ramping up for RADV audits: 5 tips to get your organization ready

With the Centers for Medicare & Medicaid Services (CMS) restarting its Risk Adjustment Data Validation (RADV) audit efforts, and the Office of Inspector General (OIG) increasing the frequency of audits, Medicare Advantage plans must shift into high gear in preparing their teams.

Now is the time to ready your risk adjustment team for the increased government scrutiny and intensity of 2024 audits. This can look different for each Medicare Advantage Organization (MAO), but generally this will require dedicated teams of well-versed and experienced audit professionals who are responsible for responding to these regulatory audits such as, RADV, OIG, etc. Even with legal challenges and settlements already underway, the audit train has left the station and is picking up steam in '24. Plans that aren’t yet ready or are ill-prepared stand to face stiff penalties, not to mention, a lot of stress!

From experience, here are five tips to help your organization get ready:

STAY INFORMED ON ANY AND ALL CHANGES RELEASED ON THE CMS AND OIG WEBSITES

CMS has a resource page where it recently published a FAQ on Contract-Level Risk Adjustment Data Validation (RADV) audits, which  states, “CMS aims to initiate the next RADV audits in the coming months and will notify MAOs at that time.” The resource link included also has additional information on RADV training and the appeals process for RADV audits.

 Similarly, the OIG is frequently updating its website with new tools available to MAOs including its long-awaited toolkit, which is intended to help MAOs replicate OIG’s techniques to identify and evaluate high-risk diagnosis codes to ensure proper payments while providing better care for their enrollees. By monitoring their sites, you can also stay on top of newly added workplan items as well as published audit reports.

PERFORM YOUR OWN INTERNAL AUDITS ON AREAS OF RISK

Using available tools such as the OIG toolkit will allow your organization to identify where high-risk areas exist within your previous coding results. Use similar queries to identify trends that need to be reviewed. Regularly conducting internal audits will identify potential compliance issues so they can be promptly addressed. Remediating overpayments will mitigate the risk of being pulled into an audit and may lessen penalties.

DON’T BE AFRAID TO INCREASE VENDOR OVERSIGHT

 Ultimately the MAO is responsible for the accuracy of any diagnosis submitted to CMS for risk adjusted payments.  While many vendors claim they can or are achieving a 95 percent or greater accuracy standard, the published OIG results clearly prove otherwise. MAOs need greater visibility into the coding activities of the vendors they contract with. Using it for purpose technology that allows your organization to have clear visibility into coding results, accuracy of the coding being produced, and the ability to immediately correct any errors and provide feedback is essential.

HAVE A STRATEGIC PLAN IN PLACE BEFORE YOU RECEIVE THAT INEVITABLE AUDIT NOTICE

Select an all-star team of highly skilled risk adjustment coders. Designate points of contact that will complete submissions.  Prepare the provider network for the upcoming medical record requests, educate providers on record retention policies and their responsibility to respond to an audit in a timely manner. 

EVALUATE AVAILABLE SOLUTIONS IN THE MARKET AND CONTRACT WITH THE RIGHT VENDORS

Scope the services that will be needed to respond to an audit in the most effective and accurate way. Assess what new and advanced technologies are available to help identify the very best records to submit to ensure the highest possible validation rates.  As good as coders are about coding, they may not be as adept at analyzing large data sets. 

Remember, the extrapolation repayment methodology is in place for PY2018 and beyond as outlined in the 2023 RADV final rule .  It is now more important than ever to complete a regulatory audit (RADV or OIG) with the highest validation rates possible to avoid very large repayment amounts.

OIG and CMS audit plans are queued and ready to go….is your organization ready?  Now is the time to get your people, processes, and tools in place to respond to regulatory audits. 

Our risk adjustment team would love to help support your organization. Please visit our website and reach out to us today to learn more about the Health Language Coder Workbench and our Regulatory Audit tool.

In case you missed it, you can now watch our recent RISE sponsored webinar, OIG Investigations! How Technology Can Help Your Team Survive the Inevitable Audit, on-demand to learn more about our technology, and make sure to swing by our booth and say hello at the upcoming RISE National conference!