Risk adjustment is a critical aspect of healthcare management. It ensures that patients with chronic or complex conditions receive the care they need while also managing healthcare costs. However, it also means that healthcare providers must be prepared for a risk adjustment audit. The Centers for Medicare & Medicaid Services (CMS) conduct Risk-Adjustment Data Validation (RADV) audits to ensure that health plans accurately report diagnosis codes for their patients. Here are the steps healthcare providers can take to prepare for a risk-adjustment audit.
What is a Contract-Level RADV Audit?
A contract-level RADV (Risk Adjustment Data Validation) audit is a type of audit conducted by the Centers for Medicare & Medicaid Services (CMS) to ensure that Medicare Advantage Organizations (MAOs) are accurately reporting the health status of their beneficiaries. The audit examines a sample of medical records to verify the diagnoses that are used to calculate the risk scores for each beneficiary.
The risk scores are used to determine the payments made by CMS to the MAOs. The contract-level RADV audit is conducted at the MAO level and is designed to evaluate the accuracy and completeness of the data submitted by the MAO. The audit is an important tool in ensuring the integrity of the Medicare Advantage program and protecting the interests of beneficiaries and taxpayers.
Steps Involving in Preparing Risk-Adjustment Audit
Risk adjustment is a crucial aspect of healthcare payment systems that ensures that Medicare and Medicaid beneficiaries receive appropriate care. The Centers for Medicare & Medicaid Services (CMS) conducts Risk Adjustment Data Validation (RADV) audits to ensure that healthcare providers accurately report diagnosis codes and receive appropriate reimbursement for their services. Preparing for a RADV audit can be a complex process, but there are several important steps that providers can take to ensure that they are prepared. This article will outline the key steps involved in preparing for a RADV audit. Here are few steps that are involved in preparing the risk adjustment audit:-
Understand the Purpose of RADV Audits
RADV audits are conducted to ensure that healthcare providers and health plans accurately report patient diagnosis codes. The CMS uses this information to calculate risk scores, which help determine Medicare Advantage (MA) payments. Accurate reporting is essential because it ensures that patients receive the care they need and healthcare providers receive appropriate reimbursement for their services.
Gather and Review Medical Records
The CMS requires healthcare providers to maintain accurate and complete medical records. These records should include diagnosis codes, treatment plans, and progress notes. Before an audit, healthcare providers should gather and review these records to ensure that they are accurate and complete. They should also ensure that the codes reported to CMS match the diagnosis codes documented in the medical records.
Train Staff on RADV Audit Requirements
RADV audits can be complex, and it’s essential to ensure that staff members are knowledgeable about the audit requirements. Healthcare providers should train their staff on the documentation requirements, coding guidelines, and other relevant policies and procedures. This training should also include education on how to respond to audit requests and how to handle any issues that arise during the audit process.
Perform a Mock Audit
Performing a mock audit can help healthcare providers identify potential issues before a RADV audit occurs. It can also help them identify areas where they need to improve their documentation or coding practices. Healthcare providers can use the results of the mock audit to make any necessary improvements and ensure that they are prepared for a real audit.
Work with a RADV Audit Expert
Working with a RADV audit expert can help healthcare providers ensure that they are prepared for an audit. These experts can provide guidance on documentation and coding requirements, help identify potential issues, and assist with responding to audit requests. They can also help healthcare providers implement best practices to ensure that they maintain accurate and complete medical records.
RADV audits are an essential part of risk adjustment in healthcare. Healthcare providers must be prepared for these audits to ensure that they accurately report diagnosis codes and receive appropriate reimbursement for their services. By following these steps, healthcare providers can ensure that they are prepared for a RADV audit and can maintain accurate and complete medical records.