For Medicare Advantage organizations (MAO), value-based care success isn’t just about delivering high-quality care – it’s also about ensuring the accuracy of risk-adjusted payments. CMS’ Risk Adjustment Data Validation (RADV) audits aren’t a matter of if but when. And when that time comes, the ability to prove accurate coding and clinical documentation can mean the difference between financial stability and steep penalties.
During the COVID-19 pandemic, audits slowed down. However, with CMS planning to resume RADV Audits in 2024 for 2018, how can health plans minimize compliance risks moving forward? The key lies in strengthening HCC management, simplifying code update maintenance, and leveraging innovative solutions to stay ahead of evolving regulations.
The RADV landscape: Why it matters
Medicare Advantage (MA) plans receive fixed monthly payments for each enrollee based on their expected healthcare costs, which are determined using Hierarchical Condition Category (HCC) codes and ICD-10-CM diagnoses. These codes translate into a patient’s risk adjustment factor (RAF) score, which ensures payments reflect the actual complexity of a population’s health rather than a one-size-fits-all reimbursement model.
RADV audits are CMS’ way of ensuring the Medicare program’s payments are accurate to safeguard taxpayer dollars. CMS can demand repayment if a plan’s submitted diagnoses don’t match the supporting medical documentation. With new rules permitting extrapolation across entire contracts, even a minor coding error in the MAO sample data submitted for audit review can have potential financial consequences.
Moreover, the implications extend beyond potential fines; such errors may negatively affect Star Ratings, increase your chances of being audited again, and impact overall revenue. So, how can you stay ahead of the curve?
Improving HCC management in clinical documentation
Inaccurate problem lists can negatively impact RAF score accuracy, preventing physicians from capturing a complete picture of a patient’s health during encounters. While internal population health teams and payers often provide gap-in-care reports highlighting potentially missing HCCs, these reports exist outside of clinical workflows, adding administrative burden and making them difficult for providers to act on.
IMO Health simplifies this process by analyzing unstructured clinical notes from past encounters and payer-sourced data to identify missing or unaddressed HCCs. By proactively surfacing these insights within existing workflows, providers can improve documentation accuracy of chronic conditions without disrupting their workflow or adding extra administrative tasks. Additionally, our solution can help alert providers of potential upcoding risks and suggest more appropriate code replacements on the patient’s problem list to ensure the patient’s diagnosis is RADV compliant.
The result? A more comprehensive picture captured in clinical documentation, improved decision-making, and opportunities for enhanced provider-payer collaboration that can help support RADV audit readiness.
Solutions to navigate regulatory code updates with ease
With the CMS-HCC model updates (transitioning from V24 to V28), bi-annual code changes, and evolving interoperability regulations, MAOs must continuously adapt their systems to maintain accurate risk-adjusted data. However, managing clinical terminology and coding systems can be labor-intensive, diverting your team’s attention from more strategic initiatives.
IMO Health simplifies this process by automatically mapping synonyms, acronyms, misspellings, and local terminology to the correct medical codes – including ICD-10-CM, CPT®, and CMS-HCCs –across all our solutions. Instead of manually maintaining diagnosis codes, IMO Health automates this process, delivering updated content five times a year to ensure value-based care success. Our continuously updated solutions ensure accurate data capture upfront at the point of care, reduce the need for post-encounter coding corrections, and minimize the risk of miscoded diagnoses being flagged during RADV audits.
Addressing legacy data: It’s never too late to correct course
You might be wondering though, what about existing patient records? Even the best forward-looking strategy can’t account for historical documentation gaps.
IMO Health’s normalization technology helps MAOs conduct retrospective internal mock RADV audits, ensuring charts align with current risk adjustment standards. It comprehensively maps structured and unstructured data to appropriate standard codes, providing specific and accurate coding to optimize downstream data use. Our intuitive interface enables organizations to review, accept, and adjust matched data as needed, helping to identify and correct potentially miscoded diagnoses and data gaps. With these insights, teams can collaborate with providers to resolve discrepancies and ensure documentation accuracy, which is critical if selected for a RADV audit.
Be audit-ready before CMS comes knocking
MA plans operate in an increasingly complex regulatory landscape. With RADV audits ramping up, being proactive is essential.
IMO Health provides point-of-care and data quality tools to help reduce the risks of clinical data discrepancies and support RADV audit readiness.
Is your clinical documentation missing HCC attributions required for a RADV audit? Get a free data quality assessment today and find out.
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