After a pause on RADV audits during the public health emergency of the COVID-19 pandemic, CMS has officially begun RADV audits for PY2018. This marks a significant moment since these audits, the first since the announcement of the RADV final rule and CMS-HCC v28, will now include extrapolated repayment penalties.
The timeline outlined by CMS for PY2018 audits is:
- MR submission window opens: November 14, 2024
- Hardship Exception Request Deadline: March 3, 2025
- MR Submission Deadline (window closes): April 21, 2025
Whether your health plan is currently facing a RADV audit, or looking to prepare for the next one, these tips can help you get ahead.
What is a contract-level RADV audit?
CMS selects a subset of Part C contracts for each annual RADV audit cycle to ensure that medical record documentation supports diagnoses submitted for risk adjustment. The purpose of a contract-level RADV is to identify discrepancies in payments by comparing RA diagnosis data that a Medicare Advantage Organization (MAO) submits for payment against documentation in the medical record.
Enrollees are sampled from each selected Medicare Advantage (MA) contract to estimate payment error related to risk adjustment. Once the enrollees have been selected, the MAO is required to submit medical records to support all CMS-HCCs in the sampled beneficiaries’ risk scores for the payment year.
MAOs are selected for audit using pre-determined eligibility criteria. From there, beneficiaries from those plans are chosen using a suspected improper payment targeting model. MAOs are typically granted 25 weeks to request and obtain medical records, review those records for best representation of audited HCCs, prepare the chart in a PDF format file with a cover sheet identifying the HCCs, and submit to a secure system such as the centralized data abstraction tool (CDAT).
Tips on how to survive a contract-level RADV audit
Here are a few tips for preparing and surviving a contract-level RADV audit:
1. Let software help you stay organized
There is a large amount of information that is involved in a RADV audit, and a fixed deadline is set by CMS. Efficiently managing your time and using effective tools such as coding software can help identify the appropriate verbiage for the HCC being audited and help identify any additional support that may be needed in order to be audit proof. Coding software should also be able to identify HCCs not being audited as those “additional HCCs” have enormous value in offsetting any potential fines or penalties. Identifying additional HCCs is especially important as MAOs are now facing extrapolated repayment penalties. Effective coding software should track pertinent information and will aid in completing an audit successfully.
Bonus tip: Identify your point of contact and audit team early for smooth project management
Select your points of contact or POCs as soon as your organization is notified that you need to respond to the audit, ensure they have access to CDAT, and all appropriate payment models and hierarchy information. Also select the coders and auditors that will be involved in the process and start those team meetings now to get everyone on the same page. According to the CMS instructions, a maximum of seven individuals, including the CEO and Medicare Compliance Officer (MCO), may be designated as POCs.
2. Prioritize and retrieve the best charts
Subsection 422.310(e) requires MAOs and their providers and practitioners to submit a sample of medical records to validate risk adjustment data. While it might be tempting to retrieve every chart that contains information for the plan year being audited, there is value in retrieving high-priority charts first. This may include charts where the HCC was initially generated from. Inpatient hospital charts are also a great source to find HCCs that need to be submitted for validation.
3. Know coding guidelines
To avoid a discrepant finding for a medical record, CMS requires the documentation be:
- Coded according to the official conventions and instructions provided within ICD-9-CM, the ICD-9-CM Official Guidelines for Coding and Reporting*
- Follow the guidance provided in the, AHA Coding Clinic for ICD-9-CM, which is published quarterly by the American Hospital Association (AHA)
- Refer only to issue dates effective at the time of encounter
RADV audits are done retrospectively, which means there is no way to query a provider for clarification when encountering ambiguous documentation. Without the ability to query, we must turn to a Coding Clinic such as, the Clinical Criteria and Code Assignment 4th quarter 2016, for guidance. The Coding Clinic is in reference to an official coding guideline that states, “The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”
Whether a physician uses the new clinical criteria for a diagnosis code, old criteria, they’re own personal clinical judgment, or something else to decide whether a patient has a particular diagnosis (and document it as such), Coding Clinic says to report the code as long as it’s documented. Essentially: the code can be assigned regardless of how the physician arrived at the diagnosis.
Per Coding Clinic, “The guideline noted addresses coding, not clinical validation. It is appropriate for facilities to ensure that documentation is complete, accurate, and appropriately reflects the patient’s clinical conditions. Although ultimately related to the accuracy of the coding, clinical validation is a separate function from the coding process and clinical skill."
4. Follow CMS rules for submissions
CMS has set very clear guidance regarding requirements for submissions to avoid discrepant findings. Medical records must include the following:
- The correct beneficiary as provided on the CMS RADV cover sheet
- Acceptable risk adjustment provider type, source, and physician specialty providing the face-to-face encounter
- Dates of service within the data collection period under review
- Valid signatures and credentials
Entering information correctly on the cover sheet will help avoid unnecessary denials. It’s important to remember, the administrative portions of this audit (i.e., patient name, acceptable provider type, date of service, signatures) are just as important as the coding itself. Coding software can aid in this part of the process, capturing important metadata that can ensure your audit process is more efficient and accurate.
5. Submit your best charts
RADV audits usually offer an option to receive early feedback. Best practice is to submit as many charts for validation as possible prior to this early feedback deadline. This strategy is invaluable to the MAO, as it allows for the submission of additional charts if one is deemed to be discrepant prior to the final deadline.
A “best chart” is generally defined as a face-to-face chart note that validates the requested HCC, plus validates an additional HCC not being audited, and contains all the necessary documentation elements (name, date of service, acceptable provider type, valid signature, and credentials or an attestation if required). Also, consider submitting a chart note that is specific to the diagnosis being validated (e.g. an oncology note for a cancer diagnosis).
This is another place where the right technology can help enhance your team's efficiency by doing the work of identifying the best charts for you.
6. Review results and make changes if necessary
As with any audit, reviewing results is imperative. This includes non-validated HCCs as well as validated results. It’s equally important to identify trends and patterns within those results. This allows the MAO to correct defects, if any are found, in its reporting to CMS for future audits.
7. Be prepared to appeal denials
At the end of the day, everyone is human, and mistakes happen. That applies to the MAO, as well as CMS auditors. All denials should be thoroughly reviewed, and appeals should be written for any discrepant finding for which you have supporting documentation to prove otherwise.
Expert support for your Medicare Advantage organization
RADV audits can seem daunting, but if you employ these strategies, they should not be as overwhelming. You, too, can successfully handle RADV audits. Contact our team to learn more about how the Health Language Regulatory Audit Module can support your Medicare Advantage organization before, during, and after a RADV audit.
*RADV Medical Record Reviewer Guidance Version 2.0 is the most updated version (in effect as of 01/10/2020) for Contract-Level 15 RADV and is applicable to dates of services that were still using ICD-9.