Tag, You’re It…RADV Selection Has Begun

The data submissions have been completed, and the Risk Adjustment Data Validation (RADV) selection process has begun. Are you prepared for what the RADV has in store for you? In April 2016, the U.S. Government Accountability Office (GAO) released a report titled, “Fundamental Improvements Needed in CMS’s Effort to Recover Substantial Amounts of Improper Payments.” This report is quite telling about the improvements needed to strengthen payment recoveries during a RADV audit. John Gorman highlighted in a previous blog, “[the Centers for Medicare & Medicaid Services] CMS is on pace for its most aggressive enforcement year ever.” So if you are one of the lucky plans that has an Affordable Care Act (ACA) plan and a Medicare Advantage (MA) plan selected for the RADV audit, my hat’s off to you because you are about to experience not one but two risk adjustment audits this year.

For those plans selected for the RADV audit, now is the time to grab your RADV readiness plan off the shelf, dust it off, and put it into action. With a very short time frame allotted for health plans to request, review, and submit the appropriate documentation to support a Hierarchical Condition Category (HCC), there is no time to waste. There are five important pieces needed to survive a RADV audit:

1. Accountability — It is important all employees involved in the RADV audit know who the person is within the company who is accountable for ensuring the RADV audit is conducted appropriately within the time frame allotted.
2. Communication — All departments need to talk consistently during the audit process because of the short time frame to deliver the best supporting documentation available.
3. Validation Review — Chart reviews should be conducted and documented in accordance with your health plan’s Coding Guidelines and Compliance RADV Policy.
4. Dispute and Appeal — Know when and how to dispute or appeal a finding from CMS.
5. Lessons Learned — When it’s all said and done, most importantly, learn from your mistakes and make strides to improve to prepare for the next audit.

If your health plan was fortunate enough not to be selected, congratulations to you for dodging the RADV selection process this year. Try not to get too comfortable with not having to participate in the RADV audit. CMS’ goal is to have all MA plans subject to an annual RADV audit, comprehensive or condition-specific. It will take time to get to this point, but be aware a yearly RADV audit is right around the corner for MA plans.

There is no need to sweat over being selected for a RADV or the potential change to an annual all health plan participation audit. Reason being, everything you are being audited on is information that was submitted by the health plan to CMS. You can’t necessarily plan for all of the unknowns or anomalies that occur during the audit, but you can certainly plan for the knowns. Health plans have the ability to ensure data quality and integrity with the risk adjustment operations that are in place prior to the data submissions to CMS. With all of the recent press and discussions about MA overpayments, health plans need to be assessing their risk adjustment internal controls. These are the primary categories for which health plans should be ensuring the right policies and processes are in place:

• Risk Adjustment Oversight — Various departments within a health plan should be providing oversight on the data submissions and operations of risk adjustment.
• Provider Engagement — Strong physician partnerships and collaboration are needed to build a long-term strategy around HCC validations.
• Risk Adjustment Interventions — Health plans need to have clear guidelines on acceptable supplemental diagnosis information obtained through interventions.
• Vendor Management — The vendors with whom health plans contract are an extension of the company. No matter how much you utilize a vendor to run your risk adjustment operations, they are not accountable to CMS during a RADV audit.
• RADV — Have a readiness plan in place and be ready to go upon being selected for the audit.

Health plans should be conducting operations as if an annual audit will occur, regardless of whether the plan is selected. There is no time like the present to ensure your health plan’s risk adjustment operations are in order.

Resources

GHG can help you streamline the execution of your risk adjustment approach, and build a roadmap to ensure you’re keeping pace with CMS expectations in both compliance and health care outcomes. Visit our website to learn more >>

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