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This webinar will discuss RADV Audits, which pertain to Risk Adjustment and how Providers and Coding Professionals, must understand, that they too, can be on the hook in the event a Medicare Advantage Plan is audited and found to have deficiencies.
CMS performs Risk Adjustment Data Validation (RADV) audits by reviewing provider medical record documentation to validate submitted diagnoses codes, as they correlate to HCC codes.
United Healthcare, Freedom Health, Humana & Aetna and Optimum Healthcare, currently are all in the scope of the DOJ for allegedly submitting risk adjustment scores that improperly inflated their Medicare Advantage reimbursement, HealthLeaders Media recently reported.
Risk Adjustment Factor Scoring or (RAF), when properly reported, allows CMS to provide additional reimbursement to Medicare Advantage Plans, based on a Members’ overall health. The RAF scores, are derived from the submitted diagnoses from what should be in the medical record. Higher weighted RAFs, correlate to sicker patients, which means a higher cost to the MA Plan to treat these sicker patients, hence, requires higher reimbursement to the MA Plans.
The main avenue in which Risk Adjustment Fraud and Abuse occurs, is by reporting chronic conditions and subsequent treatment, on patients that did not have the reported conditions or care, or upcoding on existing conditions, to make it seem more severe in nature than it is.
At the Q&A session following the live event, ask a question and get advice unique to your situation, directly from our expert speaker.
“The Beginning of Wisdom, is the Definition of Terms” - Socrates
Reasons a medical record may not be considered valid are:
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