Impacts of CMS' 2022 Advance Notice Part I on Risk Adjustment

On September 14th, 2020, CMS released their Advance Notice Part I for CY2022. CMS published this earlier than in the past to accommodate a potential early publication of the CY2022 Rate Announcement. In light of the uncertainty associated with COVID-19, an early Rate Announcement could benefit Medicare Advantage Organizaions (MAOs) by having information earlier in the year to prepare their bids, which are due the first Monday in June 2021.

While there were not any surprises, MAOs should start to think about how to align their strategies and operations to better prepare for the changes that are coming. 

100% of risk scores will be based on Encounter Data (EDS)

CMS is moving forward with their plan to fully phase in the CMS 2020 HCC risk adjustment model for Payment Year 2022 using EDS. The 2017 CMS-HCC model submitted to the Risk Adjusted Processing System (RAPS) to calculate 25% of the risk score will no longer be used. CMS will also discontinue the use of RAPS inpatient diagnoses to supplement EDS data.

Impacts: CMS is projecting the risk score impact of transitioning to the 2020 HCC risk adjustment model to be 0.25%. The CY2022 impact on MA risk scores being calculated using 100% encounter data is projected to have a neutral impact at 0.00%. Discontinuing the use of RAPS inpatient diagnoses to supplement EDS data is also expected to have an impact of 0.00%.

What MAOs can do:

1.    Perform a RAPS to EDS revenue neutrality impact analysis.

2.    Ensure risk adjustment reporting processes can be run using 100% EDS.

  • Traditional risk adjustment reporting processes (e.g., analytics, targeting, suspecting, RAF projections, and accruals) rely on processing RAPS responses to determine which member diagnoses have been accepted by CMS to drive suspecting, revenue projections, etc. Plans must start to create reporting models that solely rely on encounter data and the associated encounter data CMS response files.

3.    Ensure the completeness of supplemental data being submitted to EDS.

  • MAOs must start to ensure that all risk adjustment supplemental diagnoses data (i.e., chart reviews) are being submitted downstream to CMS via the encounter transactional system. Plans should start to evaluate this as part of a comprehensive EDS to RAPS reconciliation process.

4.    Assess the prevalence (and possible under-reporting) of behavioral health related conditions to inform population health initiatives.

  • The 2020 CMS HCC model adds more behavioral health conditions and substance use disorders. Plans could use this as an opportunity to capture a greater level of detail on behavioral health related conditions. Often times, these conditions may be under-reported and can have an impact on other population health identification and stratification programs. Additionally, behavioral health, and, more importantly, the early detection and ongoing treatment of these types of conditions can improve clinical outcomes.

Long term strategy:

In the longer term, MAOs should start to think about how the shift of 100% EDS to calculate risk scores may start to impact other operational areas:

1.    Shift to more prospective risk adjustment programs.

  • The majority of MAOs rely on retrospective chart reviews to submit supplemental diagnoses records for their MA beneficiaries. CMS will accept these types of supplemental data as linked or unlinked (i.e., linked back to the originating encounter). As CMS relies solely on encounter data for risk score calculation, plans should start the process of evaluating their risk adjustment programs and begin to think about transitioning the supplemental diagnoses submission upstream so that all of the information can flow through the encounter systems.

2.    Ensure a robust error correction and remediation process.

  • PY2021 will be last year RAPS will be accepted for risk score calculation (2020DOS). MAOs that plan on submitting EDS to CMS directly (i.e., without the use of a vendor) need to start assessing their adequacy to have a robust and timely EDS error correction and remediation process. For many plans, this means having a cross-functional business team to ensure that all encounter data records are being submitted to, and accepted by, CMS.

GHG, in partnership with Pareto Intelligence, has worked with numerous MAOs to evaluate encounter data processes and ensure accurate revenue capture. Given the increased emphasis on the EDS submission model and the growing potential for revenue shortfall, MAOs should begin assessing encounter data now to resolve issues in advance of submission deadlines.

WEBINAR: On October 8th, GHG's SVP of Healthcare Analytics and Risk Adjustment Solutions, Jeff De Los Reyes, moderated a webinar with Austin Bostock of Pareto Intelligence and Meleah Bridgeford of Episource to discuss the future of the regulatory environment, as well as steps you can take to ensure that your data is ready in advance of the submission deadline.

If you did not get a chance to attend the webinar, click here to learn more and view the recording.

by Jeff De Los Reyes

DOJ’s Increased Focus on Risk Adjustment and Compliance

As the Department of Justice (DOJ) continues its efforts to investigate the diagnosis capture and reporting practices of Medicare Advantage Organizations (MAOs), MAO executives must start to ask, “How can we most effectively report all conditions contributing to a member’s health outcomes while upholding rigorous compliance standards, when official guidance on what is considered ‘compliant’ is unclear?” 

Risk Adjustment Litigation to Date

CMS rules are clear that MAOs must submit data for risk adjustment that is both accurate and complete to give CMS a true representation of a member’s disease burden. For many MAOs, this means submitting supplemental data from chart reviews or assessment programs to add unreported member conditions. Other MAOs have taken this one step further and have initiated programs to delete member conditions that were previously submitted to CMS when they have clear evidence that the condition is not supported after a review of the physician documentation.

Most of the recent activity has been targeted at large health plans for potentially overstating the disease burden of their membership via a common practice of retrospective chart review. This practice involves reporting additional diagnosis codes to CMS abstracted from reviewing members’ medical records after the member/physician visit has already occurred. These codes were not originally submitted to the health plan by the provider. In doing so, MA plans improve accuracy of member risk scores by providing a fuller picture of the member’s health status. 

What has come into question, however, is whether plans are, or should be, “looking both ways”. Not only are diagnoses omitted from claims submission by providers, but incorrect diagnosis codes are submitted, overstating the current illness of the membership, largely by reporting ailments that have resolved or were incorrectly coded. CMS has made a strong stance that the health plan is responsible for the “accuracy, completeness, and truthfulness of the submitted data”, and submitting these codes, or turning a blind eye is in violation of the False Claims Act.

Cigna Lawsuit

The most recent lawsuit against Cigna, however, has a different focus by centering on risk adjustment programs that are more prospective in nature. The lawsuit alleges that questionable conditions were reported during special assessments called “360 assessments”. The conditions were recorded on pre-populated forms. However, they were not always verified through medical testing, were often confirmed anecdotally from patient descriptions, and were reported by providers who were not familiar with the patient’s history. 

The 360 assessments were implemented as an enhancement to the standard Medicare Annual Wellness Visit (AWV), to allow physicians to focus on assessing all chronic member conditions. The program was first deployed at Primary Care Physicians (PCPs), with incentives for completing member visits ($150 per encounter). Additional incentives were given for attending training sessions ($1,000 per training) on how to effectively perform the visit. Due to low adoption, Cigna pivoted to having external vendors perform these encounters, often in the patient’s home with a Nurse Practitioner.

The 360 assessment form utilized by Cigna is similar to other prospective member-specific assessment tools used today as part of a comprehensive risk adjustment program. These assessment tools are currently being used by either PCPs during the in-office encounter or during in-home assessments using external clinical staff. These are typically long documents covering all body systems, which allows the provider to check for positive or negative findings, along with sections to add notes. The 360 assessment form also included a section called the Health Management Report (HMR), which summarizes all of the conditions previously submitted to CMS, but without providing insight into who reported the conditions, or when.

Per the DOJ, these vendors would submit these 360 assessments to another department for diagnoses coding abstraction. The results were sent to Cigna with disclaimers instructing the intent of providing information back to the PCP for diagnosis verification. The lawsuit alleges that Cigna submitted the diagnoses from the forms to CMS to be included in risk adjustment calculations regardless of PCP verification. In fact, included in the lawsuit is documentation of a PCP rejecting a diagnosis established during a 360 encounter, and it subsequently being removed from the form.

Incentives for provider performance are outlined in the document, indicating that benchmarks for condition reconfirmation performance were set (80-85%), and volumes of encounters were shifted towards providers that met or exceeded the benchmark.

Conclusion

This recent suit goes beyond questioning accurate data submission from health plans by questioning motives of providing actionable data, compensation for program participation, and at a high-level, the need for appropriate guardrails around pay-for-performance.

The Cigna lawsuit centers on the use of prospective assessments to capture and submit risk adjustment diagnoses data. While this differs from the other DOJ investigations that focused mainly on the use of retrospective chart reviews, the alleged violation of the False Claims Act is the underlying constant in all cases. The Cigna lawsuit adds to the growing body of investigations conducted by the DOJ, which focuses on the submission of risk adjustment diagnoses data to CMS and whether these submissions are a true reflection of a member’s disease burden. 

It is becoming clear that MAOs who participate in Medicare Advantage should begin to evaluate their own risk adjustment programs and whether they are not only utilizing programs to add diagnoses to a member’s risk profile, but also whether they are doing enough to delete diagnoses from CMS which may have been submitted in error.

Where Do We Go from Here?

Here are the top 3 questions MAOs executives should start to ask their risk adjustment teams:

  1. Are my risk adjustment programs designed to collect only additional member diagnoses for submission to CMS?
  2. Do I have a risk adjustment mitigation program in place to survey diagnoses submitted on claims to determine if there is documentation risk (i.e., no documentation support for the diagnoses)?
  3. Has an independent review of the risk adjustment program been completed to assess for compliance risk?

GHG's subject matter experts can help with the development or remediation of your risk adjustment strategy. Reach out to GHG's SVP of Healthcare Analytics and Risk Adjustment Solutions, Jeff De Los Reyes, at jdelosreyes@ghgadvisors.com or Patrick Petty, Senior Consultant Risk Adjustment, at ppetty@ghgadvisors.com to start the conversation.

On October 8th, GHG’s SVP of Healthcare Analytics and Risk Adjustment Solutions, Jeff De Los Reyes, moderated a webinar with Austin Bostock of Pareto Intelligence and Meleah Bridgeford of Episource to discuss the future of the regulatory environment, as well as steps you can take to ensure that your data is ready in advance of the submission deadline. 

Our speakers shared their unique perspectives on the best strategies to deploy to ensure that your upstream encounter data is accurate, complete, compliant, and ready for submission. 

If you did not get a chance to attend the webinar, click here to view the recording.

by Jeff De Los Reyes

CMS is Changing the Medicare Advantage Risk Adjustment Model… Will Your 2021 Revenue Be Impacted?

On January 6, 2020, the Centers for Medicare & Medicaid
Services (CMS) released Part I of the 2021
Advance Notice of Methodological Changes for Medicare Advantage Capitation Rates
and Part C and Part D Payment Policies (the Advance Notice), which contains
key information about proposed updates to the Part C CMS-Hierarchical Condition
Categories (HCC) risk adjustment model and the use of encounter data.

For
the past several years, CMS has released the Advance Notice in two parts due to
requirements in the 21st Century Cures Act, which mandated certain changes to
Part C risk adjustment.

Part
1 of the Advance Notice announced a major change to the way that CMS will
calculate risk scores in 2021:

  • Encounter data (i.e., EDS) submissions will comprise 75% of a Medicare Advantage (MA) plan’s
    risk score using the 2020 CMS-HCC model

    • The
      2020 model complies with the 21st Century Cures Act, adding certain mental
      health diagnoses and including an adjustment for members with multiple HCC conditions
      known as the Alternative Payment Condition Count (APCC model)
  • RAPS data submissions will comprise 25% of the MA plan’s remaining risk score using the 2017 CMS-HCC
    model

Through
this change, CMS is continuing its trend of shifting risk-adjusted payments
towards 100% reliance on encounter data submissions. For the 2020 payment year,
the blend is 50% EDS (2020 model) / 50% RAPS (2017 model).

According
to CMS, the combined impact of the transition to a greater percentage of MA risk
scores calculated using encounter data, fee-for-service (FFS) claims, and RAPS
inpatient records is 0.00%. CMS further states that the transition to the new
model will have a .25% positive impact to RAF in 2021. 

However,
obtaining revenue neutrality or favorability may be difficult for payers who do
not have an adequate data integrity process in place to ensure that all
eligible encounters are being submitted to both EDS and RAPS. A recent study of 2.5
million MA lives led by Pareto Intelligence, a GHG partner, found that the
transition to 75% EDS submissions in risk score calculations is projected to
result in $23 per member per year (PMPY) revenue shortfall for 2021.

How
Payers Can Prepare for this Change and Mitigate Potential Revenue Shortfall

Plans should take steps now to determine the impact of the blend and model change to their risk scores and revenue, and mitigate potential adverse outcomes of the risk adjustment changes:

  • Compare 2020 midyear risk scores against 2020 final budgeted risk score. Was this in line with your expectations when you created your risk score goals during CY 2019?
    • Why This Matters: Even though 2020 payments are blended at 50% EDS/50% RAPS, any shortcomings in expected versus actual risk score performance could be magnified by the increased use of encounter data, which is an inherently more complex submission process. A better understanding of performance will give some insight into whether the blend and model change could have an adverse impact on risk scores, particularly when CMS moves to the 75% EDS/25 RAPS% split in 2021. Once you identify any gaps that may exist, you can begin to mitigate the impact of these changes to risk score calculations.
  • Accelerate data integrity and reconciliation operational processes. This reconciliation should be applied to both claims and supplemental data.
    • Why This Matters: As CMS moves towards calculating 100% of risk adjustment payments using encounter data, payers need to evaluate whether current CMS submission processes result in complete and accurate data without filtering or truncating any data that is eligible to be submitted.

      This is also critical for any risk score differences that may exist between RAPS and EDS submissions. If the advanced submission requirements and filtering logic for EDS are causing encounters that would otherwise be accepted by RAPS to be rejected by EDS, you could be leaving money on the table. Payers should evaluate data completeness and accuracy from encounter through to regulatory submission to proactively resolve issues.

The
accelerated transition from RAPS to EDS is not the only notable change in the
Advance Notice. Be on the lookout for a follow up to this article where GHG
works in tandem with Pareto Intelligence to analyze the
estimated risk score impact of the changes to the risk adjustment model.

For assistance navigating impending changes to the MA risk adjustment model and optimizing your risk adjustment program for success, please contact Jeff De Los Reyes at jdelosreyes@ghgadvisors.com.

by Jeff De Los Reyes

OIG Cracks Down on Chart Reviews in Medicare Advantage Risk Adjustment

On December 10th, 2019, the Department of Health and Human Services Office of Inspector General (OIG) released a report, which evaluated how Medicare Advantage Organizations (MAOs) used chart reviews to increase risk adjustment payments for Medicare Advantage (MA) beneficiaries in the 2017 payment year (2016 Dates of Service [DOS]). While the Centers for Medicare and Medicaid Services (CMS) did not completely agree with all of OIG’s findings, they did concur with OIG’s recommendations to provide additional oversight of MAOs.

Additionally, while the OIG study did have limitations, the findings are still highly relevant, and come at a time when CMS continues to push forward with Risk Adjustment Data Validation (RADV) audits to ensure that all diagnosis data submitted to CMS by MAOs is accurate and complete. (The payment year [PY] 2014 RADV audit started last year, and another 2015 RADV recently started.) It is important to note that CMS considers the use of RADV audits as the best approach for ensuring MAOs are documenting diagnoses appropriately.

Important Details on Risk Adjustment in Medicare Advantage

CMS risk-adjusts payment using diagnoses submitted by MAOs and pays a
higher capitated payment to MAOs that report a higher level of illness burden
for members. MAOs submit these diagnoses through two submission processes: Risk
Adjustment Processing System (RAPS) and Encounter Data Processing System
(EDPS).

To be eligible for risk adjustment, a diagnosis must be documented in a
medical record as a result of a face-to-face visit. Currently, CMS allows plans
to submit chart review diagnoses either linked or unlinked. A linked chart review
diagnosis can be traced back to a previously accepted service record or
original encounter. An unlinked chart review diagnosis occurs when MAOs cannot
identify the specific service or encounter associated to the diagnosis. It is
important to note that, at this time, CMS still considers both linked and
unlinked chart reviews as acceptable methods to submit risk adjustment-eligible
diagnoses.

Key Takeaways from the OIG Report

Below are some of the major findings in the OIG evaluation of chart
reviews in MA:

  • MAOs almost always used chart reviews to add, rather than to delete, diagnoses. Over 99% of the chart reviews in the OIG study added diagnoses.
    • In CMS’ response letter to the OIG study, CMS did state that, “chart review records are intended for the submission of additional diagnosis codes for risk adjustment. Based on their reviews of medical records, MAOs may also use chart review records to delete previously submitted diagnoses codes that are not supported by those medical records; if they identify unsupported codes, MAOs must delete them.”
  • Although limited to a small number of beneficiaries, almost half of MAOs reviewed in the study received payments from unlinked chart reviews where there was no single record of service being provided to the beneficiary. Furthermore, more than one-third of MAOs linked some, but not all, of chart reviews to original service records.
  • CMS estimated that $2.7 billion in risk-adjusted payments were paid for chart review diagnoses that MAOs did not link to any service provided to the beneficiary. However, the OIG study did not take into account the blended payment model (RAPS/EDPS) with this calculation. The actual value of these payments using the blended model is approximately $675 million.

Implications for Medicare Advantage Organizations

As a result of these findings, OIG made three recommendations to CMS
with which CMS agreed. Below are the recommendations along with implications
for MAOs:

Provide targeted oversight of MAOs that received risk-adjusted payments resulting from unlinked chart reviews for beneficiaries with no service records in the 2016 encounter data.

Implications:
MAOs that submitted chart review diagnoses, but did not submit any other
service records for the beneficiary, were reimbursed by CMS to care for the
member; however, no evidence of services or treatments that MAOs provided to
these beneficiaries was submitted to CMS.

What MAOs Can Do:
Evaluate overall data integrity and perform an in-depth analysis of the process
for submitting complete RAPS and encounter data to ensure that all appropriate
service records are reported to CMS. Improved data quality can also improve the
rate of linking chart review diagnoses to original encounters. This is
especially important as CMS
continues to rely on encounter data more than RAPS submissions for risk
adjustment payments, which was announced the
latest CMS Advance Notice.

Conduct audits that validate diagnoses on chart reviews in MA encounter data. 

Implications: 2015
was the first year in which CMS started to use encounter data to calculate risk
adjustment payments. CMS has stated that they will include diagnoses from chart
reviews in RADV audits.

What MAOs Can Do:
Perform an over-read validation audit on a sample of chart review diagnoses
submitted to CMS that resulted in payment. If any chart review diagnoses fail
validation, MAOs can submit these as deletes to CMS (even if the period is
closed). In general, MAOs should consider the use of chart reviews to submit
both adds and deletes to CMS—i.e., incorporating a “two-way look” for HCCs,
especially on claims.

Further, MAOs should implement an HCC compliance program
and/or a rigorous QA/over-read process as part of an overall risk adjustment
strategy to ensure that diagnoses from encounters, as well as diagnoses from
chart reviews, are accurate and valid. This is especially important for MAOs
who use a third-party vendor for chart review coding.

A comprehensive compliance program must include ongoing
evaluation throughout the year that identifies and validates diagnoses that are
at high risk of being submitted erroneously without the proper documentation,
as well as the performing of outlier audits.

Reassess the risks and benefits of allowing chart reviews that are not linked to service records to be used as sources of diagnoses for risk adjustment.

Implications: At
this time, CMS will continue to allow the use of chart review records both
linked and unlinked as sources for risk adjustment payment. However, this may
not always be the case, which would result in a reduction of payments for MAOs
that submit a high number of unlinked chart review records.

What MAOs Can Do:
As best practice, MAOs should continue to submit both linked and unlinked chart
review records to CMS. The linking of chart review records to the original
encounter can be complex and burdensome to an organization’s submission process
infrastructure. However, MAOs should evaluate current chart review processes,
specifically around the linking process and logic, to identify whether the linking
logic is too stringent and to submit more chart review diagnoses as linked
records. As an example, MAOs can identify cases where previously unlinked chart
review records can be linked back to the original encounter by analyzing the
use of rendering versus billing provider and DOS ranges in the linking process.
If MAOs use a third-party vendor for chart review, there must be adequate
vendor oversight and QA of the submitted codes.

Lastly, MAOs should start to implement and invest in
prospective provider programs (including concurrent chart review) to capture all
relevant member diagnoses at the point-of-care and ensure data is both
documented in the medical record and submitted  appropriately on the claim/encounter that is
submitted to the health plan.

Conclusion

Historically, MAOs have used risk
adjustment programs like chart reviews to enhance risk-adjusted payments from
CMS by supplementing submissions to CMS with more complete diagnoses data from chart review programs. MAOs should
evaluate current risk adjustment programs to ensure payments from CMS are both
complete, and more importantly, accurate. Accuracy in risk adjustment should
include “looking both ways” by using chart reviews to add and
verify/delete diagnoses from previously submitted encounters.

Please contact Jeff De Los Reyes, leader
of Risk Adjustment and Healthcare Analytics Advisory practice at Gorman Health
Group, at jdelosreyes@ghgadvisors.com
for more information.

by Jeff De Los Reyes

Compliant Coding and Documentation: Minimize Compliance Risk with CMS through HCC audit programs

Was your plan selected for this year’s Medicare
Part C Contract-Level Risk Adjustment Data Validation (RADV) audit of 2014
dates of service?  Have you participated
in a Department of Health & Human Services (HHS) Office of Inspector
General (OIG) audit related to risk adjustment submissions? Does your plan
participate in the Affordable Care Act (ACA) individual and small group
marketplace?  Are you a provider who was
asked to supply records for any audit related to risk adjustment and/or are you
in a risk bearing agreement with one or more payers for Medicare Advantage (MA),
ACA, or Medicaid?

If you answered “yes” to any one of
these questions, you know what a critical role documentation and coding plays
in a risk adjustment program.  Even plans
and providers who answered “no” to any of the questions should have a program
in place to mitigate compliance risk when it comes to the accuracy and
integrity of data being sent to CMS.  CMS
requires health plans to submit accurate and complete risk adjustment data that
are fully supported in the medical record with adequate evidence that a
condition exists and is being managed.  A
comprehensive, year round Hierarchical Condition Category (HCC) audit program
should be an important part of any risk adjustment program in order to mitigate
risk with CMS in the future. 

A
well-rounded HCC compliance program should include the following components:

  1. Coding policy due diligence – Review of internal coding guidelines
    and policies and procedures of coding practices (for plans with internal coding
    teams).  Review of vendor coding policies
    and performance service-level agreements (SLAs) included in coding contracts.
  • Mock RADV – Replicate the entire RADV process
    from analytics required to identify the source of the HCC for validation to
    creating the provider chase file and requesting the medical records for
    validation of the HCC.  A RADV requires
    the coordination of multiple business units to meet the strict and constricted
    timelines of CMS.   RADV preparedness
    will ensure all business units know their role in the RADV and can execute
    effectively if your plan is selected.
  • Targeted Diagnoses Audit – Identify potential “high risk” diagnoses
    codes submitted on claims and validate these against the medical record to
    ensure that sufficient documentation exists to support these diagnoses.  Examples include ”single occurrence” diagnoses
    where there is only one instance of the diagnoses submitted for a member in a
    calendar year by only one provider.
  • Provider Outlier Audit – Identify providers who have a
    significantly higher prevalence of members with specific chronic conditions
    than your plan’s average, based on their claim submissions.  Also, look at the pattern of diagnoses being
    submitted by provider specialty types and identify outliers or mismatches.  For example, some chronic conditions are more
    suited to be assessed and managed by certain specialists versus other specialty
    types.  Payers can mine this data and
    pull medical charts for these provider outliers to review the medical record
    against the claim submission.
  • Vendor over-reads: 
    Most payers or providers outsource some or all of their retrospective
    chart reviews or prospective assessment programs to external coding
    vendors.  These vendors then submit the
    supplemental diagnoses for submission by the health plan.  Typically, coding vendors have performance SLAs
    to ensure 95% or greater accuracy based on the vendor over-read of a sample of
    their charts. Payers should also perform an independent review of their coding
    vendors to ensure the accuracy of the diagnoses being submitted.
  • Detailed and technically sound delete
    process infrastructure    :  In any instance where a diagnoses is found to
    have insufficient evidence in the medical record, payers are obligated to
    delete the diagnose codes from a CMS submission.  It is important for payers to have a thorough
    understanding of their delete process to ensure they are not over-deleting
    diagnoses codes that could lead to potential negative financial
    consequences.  Prior to any delete
    project resulting from an internal audit, plans need to examine the potential
    financial implications that might affect their budgeting and accrual process.
  • Provider
    feedback and Clinical Documentation Improvement:      If
    any diagnoses are found to be unsupported in the medical record, it is
    imperative that providers are educated on the importance of proper
    documentation and coding, to avoid the re-occurrence of the submission of any
    unsupported diagnoses.  Plans should have
    a robust provider feedback loop so that providers are continually kept abreast
    of how they are documenting and coding, and if needed deploy a clinical
    documentation improvement plan.

Risk adjustment plays a critical role in
revenue generation for payers who participate in government sponsored programs
such as MA.  Putting in place a risk
adjustment clinical documentation compliance program will enable payers to
avoid financial risk in the case of a potential MA RADV extrapolation and/or an
ACA marketplace adjustment following an Internal Validation Audit (IVA).

CMS HCC RADV audits are here to stay and
plans that participate in the ACA marketplace are already familiar with the IVA
requirements.  Many plans have also been
targeted for an OIG audit.  CMS is
looking to use these audits to recoup improper payments to plans which may have
a significant financial impact.  Plan and
provider executives at all levels - including the Chief Executive Officer (CEO),
Chief Financial Officer (CFO), and Compliance Officers - should evaluate what
programs they have in place to mitigate future audit risks.

Whether you already have a risk adjustment compliance program in place and need an independent review of these programs against best practices or are thinking about designing and implementing a program, we can help.  For additional questions and inquiries about how GHG can help, please contact me at jdelosreyes@ghgadvisors.com.

by Jeff De Los Reyes