Holly Cassano - CPC, CRC, AAPC, ICD-10-CM Certified Tags: , , , , Compliance, Practice Management
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CMS audits for risk adjustment – will RADV be upgraded and intensified POST UNITED, HUMANA, FREEDOM INVESTIGATIONS?

When CMS proposed expanding the risk adjustment audit program in 2015, it was looking to cover all Medicare Advantage (MA) Plans, annually.  CMS wanted one of two conditions:

  1. Condition-Specific
  2. Comprehensive Audits

CMS wanted one of the two implemented due to the fact that the powers at be then, strongly believed that the diagnosis data was fraught with epic upcoding mistakes which were being submitted by all the MA organizations.  This was a concern for CMS as they were concerned that there would be significant misallocation of resources.  Some MA Plans might be overpaid on their members and some might be underpaid on their members.

At the time, CMS audited only five percent of all MA Plans annually and that is still in place as of 2017.  In order for CMS to move to one of the two models it is looking to adopt, there will have to be significant policy changes.  In light of recent headlines, alleging upcoding by The Big Three – United, Humana, Freedom and other MA Plans and the DOJ stepping in – it would seem that 2017 may be the year of the MA RADV overhaul.

Related webinar: Risk Adjustment and RADV Audit webinar video

What we know:

MA’S & Providers feeling increased pressure for accuracy

  • Risk Score Accuracy is Mission Critical to avoid upcoding or HCC Creep
  • OIG will add to annual Work Plan – most likely in light of the big three fraud investigations this year
  • RAC intensity possible – also on the heels of the big three fraud investigations this year

RAPS (Risk Adjustment Processing System) to EDPS (Encounter Data Processing System)- as of 2020, MA Plans will be subject to 100% EDPS for records (currently 25% of Risk Scores are based on EDPS/75% is RAPS)

  • Tighter Filters in 2020 – to more accurately determine Risk Scores
  • Could result in possible 3-4% downtick impact for some MA Plans, if they don’t implement changes now to how they capture HCCs/RXHCCs
  • Sunset of RAPS by 2020 – it is proving to be an outdated and inaccurate model to capture RA data during sweeps

Two audit types for RADV

CMS and HHS each have their own version of RADV Audits they conduct based on two different HCC coding models:  CMS-HCCs and HHS-HCCs.  Each model is designed to capture population complexity and severity. To be more specific, the CMS/HCC model was adapted into the HHS/HCC Model and is utilized within some of the Alternate Payment Models (APMs), which also includes Advanced APMs.


CMS-RADV audits are occur annually and are comprised of two focus areas:

  • National Sample – which consists of a small group of MA Plan members and focus on calculating error rates without identifying financial impact
  • Targeted Audits – are broader and intensive in nature. They are made up of a random sample from 201 MA Plan members. Targeted audits place the burden of proof on the MA Plan, to produce a valid face to face encounter for each date of service/claim submitted previously by the MA Plan. Each medical record must be able validate each reported diagnosis that correlates to an HCC/RXHCC submitted to CMS by the MA Plan.


All MA Plans are required to annually participate in a Health Exchange or (HIX), RADV audit.  These audits are comprised of a 200 Plan member sample for each MA Plan. HHS RADV Audits, also place the burden of proof on the MA Plan, to produce a valid face to face encounter for each date of service/claim submitted previously by the MA Plan.  Each Medical record must be able validate each reported diagnosis that correlates to an HCC/RXHCC submitted to HHS/CMS, by the MA Plan.   The HIX HCC Program is designed based on budget neutrality and the outcome will reflect MA Plan performance and overall drive the payments owed to all competing MA Plans.


Member Name: HCN:

Image ID: ________  DOS:________ Page #: ________

HCC: Diagnosis Code(s): ___________________________

  • Is the correct member name on the Admission or Date of Service (ADM/DOS)?
  • Is the ADM/DOS for the correct year?
  • Does the documentation support a face-to-face visit?
  • Is the ADM/DOS from a valid provider type and setting?
  • Is the provider credentials/specialty documented on the ADM/DOS?
  • Does the ADM/DOS contain an acceptable (legible) signature with date?
  • If not, is a CMS-Generated Attestation needed for this DOS?
  • Is the record for the correct calendar year for the payment year being audited?
  • Is the date of service present for the face to face visit?
  • Is the record legible?
  • Is the record from a valid provider type?
  • Are there valid credentials and/or is there a valid physician specialty documented on the record?
  • If the outpatient/physician record doesn’t contain a valid credential and/or signature, is there a completed CMS-Generated Attestation for this date of service?
  • Is there a current (legible) diagnosis that supports the HCC requested?
  • If yes, does condition meet reporting criteria (MEAT)?
  • If not, does the documentation support a higher weighted HCC?
  • If not, does the documentation support a lower weighted HCC?
  • Are any additional HCCs supported on this ADM/DOS?

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The wrap up

We know there is active talk of CMS creating a new kid on the block for Risk Adjustment Audits, the Medicare Advantage Recovery Audit Contractor Program, (MARA? Possibly our new acronym).  If CMS does move forward this year or next and create a bigger, badder, version of RADV, I venture to say that MA Plans and Providers will need to work together, along with Certified Risk Adjustment Coders (CRC).  They all will have to be focused on compliance with any new requirements/ changes that may be implemented under a potential a “MARA” Contracting Program.   Additionally, I will venture to say that extrapolation, may well be involved in any investigated and proved cases.

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Holly worked for BillingParadise as one of our Regional Directors of RCM, Risk Adjustment, and Quality & Client Services, She was invited by the AAPC to be one of 7 people in 2014, to help develop The CRC National Credential & Exam. She is our resident Risk Adjustment Subject Matter Expert amongst other specialties.

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