How to Avoid CMS RADV Audits With Prospective Risk Adjustment

Roxanna Cross
Fri 3 Nov 2023
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Risk adjustment programs play a fundamental role in correctly assessing and documenting a patient's health. These programs predict service needs and craft effective care models, which result in the cost-effective improvement of health outcomes.

Having timely access to accurate data is critical for successful risk adjustment. It helps avoid potential negative repercussions that arise from insufficient data submission. Penalties, and lost revenue intended for vulnerable Medicare Advantage beneficiaries, can be the consequences of incorrect data submission or unsupported reported diagnoses. Other potential issues include failed audits, repayment requests from CMS, and potential legal ramifications.

For Medicare beneficiaries to receive optimal care, it is crucial to ensure accurate payments to Medicare Advantage organizations (MAOs). This accuracy is achieved through risk-adjusted payments by CMS, whereby MAOs receive higher capitated rates for beneficiaries with elevated risk scores.

However, this system might motivate MAOs to inflate beneficiaries' health conditions to receive higher payments. CMS estimates that between 2013 and 2016, Medicare had overpaid by approximately $40 billion. These overpayments stemmed from diagnoses that lacked evidence from the beneficiaries' medical records.

Innovaccer conducted a national flash survey to delve into the challenges payers face in risk adjustment. The online survey involved 43 payer leaders at the C-suite, VP, and director levels. These leaders were well-acquainted with their organization's initiatives and strategies.

Fig. 1: What are the top 3 areas you have experienced the biggest challenges?

Our survey highlighted that member engagement is a top challenge in the risk adjustment framework for 50% of healthcare leaders. Other significant challenges include provider engagement at the point of care, clinical data integration, and risk adjustment coding gap analytics.

Digital transformation tools like clinical data integration and advanced analytics can help health plans address these issues and enhance performance. These tools facilitate actionable insights at the point of care, driving improved financial, clinical, and operational outcomes for members and providers. To achieve these goals, it's crucial to boost both member and provider engagement.

Effective member engagement mandates health plans prioritize their relationships with providers, as communicating with members through these providers is essential. Digital collaboration with providers is also vital for speeding up clinical data management at the point of care.

Health plans bear the responsibility of ensuring coding accuracy, managing risk-based contracts, and boosting population health. As CMS regulations shift towards reducing retrospective coding submissions, many plans aim to decrease their dependence on retrospective medical record reviews.

The focus is on prospectively engaging members and providers to manage, treat, assess, and accurately code conditions each year. Through these initiatives, health plans can boost member and provider engagement, leading to improved health outcomes and plan performance.

The U.S. Department of Health and Human Services Office of Inspector General's report, titled "Billions in Estimated Medicare Advantage Payments From Chart Reviews Raise Concerns", illuminates several issues. Firstly, there could be a data integrity problem if MAOs neglect to submit all necessary service records.

Secondly, there might be a payment integrity issue if diagnoses are inaccurate or unsupported, leading to incorrect risk-adjusted payments. Lastly, there could be a quality-of-care problem if beneficiaries don't receive necessary services for potentially severe diagnoses listed on chart reviews lacking service records.

In the current healthcare landscape, payers face increased regulatory scrutiny, the threat of penalties, and a higher risk of failed audits by the Office of Inspector General. The recent changes to the RADV (Risk Adjustment Data Validation) program have intensified these concerns. Therefore, it's crucial for payers to adapt and ensure compliance with CMS regulations while preserving accurate payment integrity.

Inside A High-Integrity Risk Adjustment Program

The premier step to avoiding  CMS RADV audits hinges on the creation of a high-integrity risk adjustment program—one that enhances the bond between provider and member to positively impact patient care and boost provider coding accuracy. Medical documentation is the cornerstone of accuracy in risk adjustment; and such a program works to ensure compliance with CMS regulations, mitigate audit risks, and preserve precise payment. Thus, forming robust partnerships with healthcare providers becomes crucially important. That said, here are the three pillars of a successful high-integrity risk adjustment program.

  1. Identifying Risk Areas for Audit Failures

    The OIG pinpoints two areas where audit failures are more likely: home assessments and retrospective medical record reviews. This underscores the necessity for payers to focus more intently on these aspects of risk adjustment and invest in solutions to curb these risks.

  2. Appreciating the Significance of Prospective Risk Adjustment Programs

    It's impossible to overstate the importance of prospective risk adjustment programs. These plans aim to bring functions closer to the point of care, facilitating doctors to have data at their disposal sooner to inform patient monitoring, diagnostics, and treatment plans better. By strengthening documentation and coding at the source, a prospective and concurrent risk adjustment program shifts risk adjustment into a clinically relevant, member-focused activity, not merely a code collection exercise. This methodology bolsters stronger provider coding over time, helps ensure that encounter data mirrors the medical record, bridges future gaps, and boosts provider-member engagement, leading to a superior member experience and care quality.

  3. Weakening Dependence on Retrospective Record Reviews

    A key advantage of prospective risk adjustment programs lies in their ability to reduce reliance on expensive and intrusive retrospective record reviews. Such reviews expose your plan to heightened audit risks and offer little (or even no) value to member health. By diverting the focus towards real-time, member-centered data, prospective risk adjustment programs help ensure consistent documentation and coding accuracy by addressing potential audit issues in advance.

The Path to Success in RADV Audits

In conclusion, the swiftly changing landscape of healthcare regulations and audit procedures necessitates a proactive approach from payers. Implementing prospective and concurrent risk adjustment programs ensures ailments receive proper management, treatment, and assessment. With the CMS RADV audit process becoming increasingly stringent, it's crucial that payers invest in high-integrity risk adjustment programs.

By taking this step, payers can minimize the risk of OIG audit failures and penalties, simultaneously improving member experience significantly. Prospective risk adjustment programs hold the key to ensuring accurate documentation, coding, and member-centered care, creating a win-win situation for both payers and members.

Using the appropriate tools and data platform allows for seamless data sharing between payers and providers, circumventing significant disruption to workflow. Through digital chart retrievals and access to a 360-degree longitudinal view of members, payers can enhance the precision of risk adjustment profiles, without ramping up provider irritation. Additionally, healthcare payers can aid providers in pinpointing and closing care and coding gaps.

By implementing strategic initiatives toward risk adjustment improvement, payers can streamline and accumulate accurate data, synchronize physician workflows, and employ contextual insights to run analytics, visualize data, boost care quality, bridge coding gaps, and identify areas for strengthening their relationship with providers. In turn, this secures success in RADV audits.

How Can Innovaccer Help?

Innovaccer’s solutions accelerate digital transformation and collaboration between payers and providers, enabling a more prospective and concurrent process for risk adjustment resulting in:

  • High integrity risk score accuracy
  • Enhanced member experience
  • Greater program efficiency

Innovaccer’s risk adjustment and coding gap analytics help ensure compliant and accurate compensation for Medicare Advantage, ACA Commercial, Medicaid, and VBC populations. Our recapture and advanced suspecting gap identification methods are optimized for claims and clinical data with triggers and links to support encounters, clinical evidence, and accurate risk capture, and improve care quality and member health outcomes.

Provider engagement is by far the most influential lever to improve risk score accuracy and members' healthcare experience. Learn how your organization can engage providers at point-of-care to improve risk adjustment with Innovaccer's InNote for payers.


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Tags:  Risk Adjustment
Roxanna Cross

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