Be prepared for all types of federal audits with a new conference for health care professionals. The RISE Audit Readiness Master Class will take place January 13-14, 2025 with a half-day preconference workshop on January 12, at the Sheraton Phoenix Downtown. In this article, we talk to two speakers about what attendees can expect during their sessions.
RISE’s new event will arm audit professionals from managed care health plans with the tools they need to successfully manage the full spectrum of audits from Office of Inspector General (OIG), Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services (HHS), and Risk Adjustment Data Validation (RADV).
The agenda includes a preconference mock audit simulation on Sunday, January 12, and main conference sessions January 13 and 14 on CMS program audits, sample audits, chart retrieval, audit preparation, differences between varying types of audits, and solutions and tools to improve audit performance.
Donna Malone on the audit crisis impacting the health care industry
The main conference will begin with a two-part look at the state of the industry. Donna Malone, CPC, CRC, AAPC approved Instructor, AHCCA, RAP, director risk capture, population health management, Mass General Brigham, will lead the first part with an examination of the audit crisis impacting the health care industry.
One focus area will be the 2018 RADV audit, which began November 14. CMS has published audit methods, instructions, questions and answers, and for the first time has announced the names of the 60 plans chosen for the audit. Previously, only the plans selected for the audits were informed but CMS is being more open about the process.
Malone notes that the audits are significant because CMS will extrapolate RADV audit findings for payment year 2018. “So, the extrapolation now starts and it’s a very complicated formula because in value-based care you have to take into consideration adjustments…and it leads to a lot of money,” she said. An error rate for an HCC may be applied across all HCCs, depending on the hierarchy.
She’ll also dig deep into OIG audits, the watchdog’s recently released work plan, and its move to expand the number of conditions it will review, adding pressure ulcers and sepsis in the office. “Everybody’s complaining about OIG audits, that they’re not doing it right. Well, I don’t believe that. If you read their algorithm, it's extremely fair. Now OIG actually released the playbook with the SAS or SQL code. They’re expecting you to clean things up and when they find things aren’t being cleaned up, you are going to get a knock on the door,” she said.
Mary Inman on the legal impact of non-compliance
Mary Inman, partner, Whistleblower Partners, will take the lead on the second part of the state of the industry. She’ll provide a lawyer’s perspective, discussing the different types of fraud, waste, and abuse that have been identified in lawsuits; recent whistleblower cases that alerted the OIG and Department of Justice to investigate fraudulent activity involving Medicare Advantage plans and risk adjustment; and how plans can implement changes to eliminate fraud, waste, and abuse.
“It’s a great opportunity for me to talk about audit-related frauds and the risks that audits pose,” Inman said. “Audit readiness is important, but I would say my presentation is kind of like audit wariness. You should be wary about what can happen if you’re not compliant on your audit.”
She’ll talk about the patterns and trends she’s seen in fraud cases and the type of behavior that could get health plans in trouble, such as failure to delete diagnoses codes that are unsupported and that were identified in an internal audit. Inman stresses that while it makes good sense to conduct audits, plans must be serious about correcting errors within 60 days from the date they became aware of them, and not waiting until the government comes knocking to conduct its own audit.
“The knowledge that you gain, you cannot sit on it. You need to act on it. If you don’t, there are real repercussions,” she says.
The RISE Audit Readiness Master Class will take place January 13-14, 2025, with a half-day preconference workshop on January 12, at the Sheraton Phoenix Downtown. Both Malone and Inman will speak on Monday, January 13. Click here for details on the agenda, roster of speakers, and how to register.