Internal Controls – Taking the “Risk” out of Risk Adjustment
Risk adjustment has become more and more of a “hot topic” these days. The critical implications and takebacks that occur with submitting unsupported diagnosis information and data inaccuracies are staring to become more real for a lot of health plans. This year, the Government Accountability Office (GAO) took aim at the lackluster auditing around risk adjustment the Centers for Medicare & Medicaid Services (CMS) was providing. With this high-stakes visibility, it is quite clear the Medicare Risk Adjustment Data Validation (RADV) and Commercial Risk Adjustment Data Validation (H-RADV) will start to become stricter over time. The industry has already started to see a greater focus from CMS with developing more refined processes for the 2015 H-RADV audit that is currently being conducted. There are a lot of intricate details very specific to RADV and H-RADV processes health plans need to make sure they are monitoring and preparing for.
Auditing for risk adjustment is no longer a matter of “if” your organization will be selected but rather “when” your organization will be selected. Here we are in 2016, and CMS is initiating Medicare takeback payments for unsupported diagnoses from 2009 dates of service data submissions. The lapse of time between the data submission and payment adjustment is quite significant. Certainly not something a Chief Financial Officer likes to see.
Although the H-RADV and RADV auditing timelines and processes are significantly different, the underlying foundation of being prepared is the same. Data validations are labor intensive for many departments throughout the organization because they require optimal attention to detail. In order for a health plan to ensure all minute details are addressed appropriately, a readiness plan with specific processes and corresponding time allocation needs to be in place. This allows all departments involved to have visibility into knowing what is expected of them “when” information needs to be provided for a data validation audit. Dedicated individuals will be able to spend more time paying attention to detail in their assigned task rather than rushing to figure out a plan to produce the needed information requested by CMS.
A lot of health plans are firm believers that conducting 100% chart reviews is the golden ticket to being proactive against adverse data validation results. Conducting chart reviews and coding validations are only half of the battle. The increasing visibility of risk adjustment requires risk adjustment auditing best practices become a way of life and are visible in the day-to-day core operational and technical processes that are established.
Building foundational processes around the operational risk adjustment best practices and developing a RADV/H-RADV Readiness Plan will put your organization in a good position “when” the time comes.
Contact us today to learn more about how GHG can help your organization develop best practice approaches to risk adjustment and create a RADV/H-RADV Readiness Plan.
Resources
New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG’s Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
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