{"id":4073,"date":"2017-07-31T10:15:25","date_gmt":"2017-07-31T15:15:25","guid":{"rendered":"https:\/\/www.billingparadise.com\/blog\/?p=4073"},"modified":"2026-03-11T02:53:46","modified_gmt":"2026-03-11T07:53:46","slug":"radv-overhaul-2017","status":"publish","type":"post","link":"https:\/\/www.billingparadise.com\/blog\/radv-overhaul-2017\/","title":{"rendered":"CMS RA\/HCC AUDITS: WILL RADV RAMP UP – POST UNITED\/HUMANA\/FREEDOM INVESTIGATIONS?"},"content":{"rendered":"

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CMS audits for risk adjustment – will RADV be upgraded and intensified POST UNITED, HUMANA, FREEDOM INVESTIGATIONS?<\/h3>\n

When CMS<\/abbr> proposed expanding the risk adjustment audit program in 2015, it was looking to cover all Medicare Advantage (MA) Plans, annually.\u00a0 CMS<\/abbr> wanted one of two conditions:<\/p>\n

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  1. Condition-Specific<\/strong><\/li>\n
  2. Comprehensive Audits<\/strong><\/li>\n<\/ol>\n

    CMS<\/abbr> 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<\/abbr> organizations.\u00a0 This was a concern for CMS<\/a> as they were concerned that there would be significant misallocation of resources.\u00a0 Some MA<\/abbr> Plans might be overpaid on their members and some might be underpaid on their members.<\/p>\n

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    \"\"<\/div>\n

    At the time, CMS<\/abbr> audited only five percent of all MA<\/abbr> Plans annually and that is still in place as of 2017.\u00a0 In order for CMS<\/abbr> to move to one of the two models it is looking to adopt, there will have to be significant policy changes.\u00a0 In light of recent headlines, alleging upcoding by The Big Three – United, Humana, Freedom and other MA<\/abbr> Plans and the DOJ<\/abbr> stepping in \u2013 it would seem that 2017 may be the year of the MA<\/abbr> RADV<\/abbr> overhaul.<\/p>\n<\/div>\n

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    Related webinar<\/strong>: Risk Adjustment and RADV Audit webinar video<\/span><\/div>\n
    Watch Video Now<\/a><\/div>\n<\/div>\n<\/div><\/div>
    <\/div><\/div><\/div><\/section>

    What we know:<\/h3>\n

    MA<\/abbr>\u2019S & Providers feeling increased pressure for accuracy<\/strong><\/p>\n