Risk Adjustment Data Validation (RADV) Audits Just Got Real

February 19, 2015
|In Compliance, Performance Optimization, Provider Relations, Strategy, Risk Adjustment, Prospective Evaluations
|By GHG Advisors

Last night the second-largest Medicare Advantage plan in the country, Humana, filed an SEC document detailing a US Department of Justice investigation into the company’s risk adjustment coding and data collection practices.  The investigation is an extension of a 2010 physician-led whistleblower action under the False Claims Act.  The company has over 3.2 million Medicare Advantage members.

For years CMS has struggled to define the process and methodology it would use to pursue payment recoveries from Medicare Advantage plans which were overpaid under risk adjustment.  In 2012 it finalized its process and launched its first round of RADV audits, on a parallel track with those being conducted by the Office of Inspector General at the Department of Health and Human Services.

The Justice Department’s involvement in the Humana audit would appear to indicate the review is in the advanced stages and has been underway for some time.  The methodology assures an extrapolated repayment to the Federal government for unsubstantiated codes submitted for risk adjustment.  That this action also comes in connection with the False Claims Act and a qui tam whistleblower action could signal serious trouble for the insurance giant.

RADV just got real.

 

Resources

GHG can support your risk adjustment from start to finish when it comes to preparing for your RADV audit and prepare a readiness plan. We’re standing by to support you in comprehensive audit coordination, limited audit oversight and targeted engagement services. Visit our website to learn more >>

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