Risk Adjustment Fraud! Is your Practice at Risk?

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Kim Dues

Webinar schedule and description1:30PM EST - JUL 26TH, 2017 - Expired

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Holly Cassano


Risk Adjustment Fraud, Not Just Another “F” Word, Is Your Practice At Risk For An Audit?

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.

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Importance of webinarWHY SHOULD I ATTEND?

  • Healthcare office managersWe will discuss and give an overview of Risk Adjustment documentation guidelines, and the audit risk of not accurately documenting face to face visits, thoroughly.
  • Healthcare office managersWe will discuss what CMS looks for in a RADV Audit and how to Bullet Proof your documentation and coding.
  • Healthcare office managersWe will discuss RAF Scores for members and their significance and triggers for an audit
  • Healthcare office managersWe will discuss what is an appropriate provider query from a Plan, on a members health record
  • Healthcare office managersWe will discuss MEAT – (Monitored, Evaluated, Assessed & Treated), and help Providers and Coders understand that each diagnosis must be documented to the highest degree of specificity, so that the most specific ICD -10 code(s) can be assigned and reported.

Healthcare representativesWHO SHOULD ATTEND?

  • Healthcare office managersFACILITIES
  • Healthcare practice managersMA PLANS
  • All certified coders who work in the risk adjustment arena, private practice, facility or a MA plan
“The Beginning of Wisdom, is the Definition of Terms” - Socrates
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Webinar schedule and descriptionSESSION AGENDA

We will discuss the reasons a medical record may not be considered valid in a RADV Audit:

Reasons a medical record may not be considered valid are:

  • Mistaken record/no name
  • Provider’s signature missing or not legible
  • Enrollee’s name variation
  • Date of service missing
  • Invalid provider submission type; lab only, super-bill, non-face-to face, skilled nursing facility (SNF)
  • Provider’s credentials missing
  • Data submitted outside data collection period
  • We will discuss what to do in the event, your practice is audited

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