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Blog   |   5.28.20

Following Deferred Audits, a Renewed Focus on Risk Adjustment Compliance

Risk Adjustment RADV Audits and Compliance

The trajectory of Medicare Advantage (MA) and other risk-adjusting government programs has been pointed toward increased regulatory oversight. As Medicare enrollments continue to climb year over year and Affordable Care Act (ACA) membership holds steady, CMS and HHS are concerned with appropriately stewarding taxpayer money and holding program administrators accountable for compliance with federal regulations. 

Heading into 2020, plans and at-risk providers serving MA and ACA members received clear signals that government regulators would be turning up the heat on RADV audits, IVAs, and other types of compliance inquiries. In September 2019, Kaiser Health News filed a lawsuit against CMS to release previous RADV findings to the public in the wake of an analysis that uncovered $30 billion in overpayments made to MA organizations from 2016 – 2018. In December 2019, the Office of the Inspector General (OIG) launched a review of 2016 supplemental MA codes and found that over $2.7 billion dollars were paid out to plans for conditions not represented on encounter claims; they subsequently recommended CMS pursue additional audit measures to ensure accurate supporting condition data is submitted for reimbursement. And in March 2020, the Department of Justice filed its latest FCA lawsuit against a large national payer for improper risk adjustment coding practices between 2014 – 2018. 

In the wake of the COVID-19 pandemic, the momentum behind oversight activities has slowed. Data validation audits have been delayed; RADV audits for 2015 dates of service have been postponed; and program audits are suspended until the public health emergency ends. However, these reprieves are only temporary. When health plans and provider groups gain their footing, there’s no question that regulators will continue to ramp up audits and other compliance inquiries. Given the extensive provisional regulatory changes impacting risk adjustment over the past few months, including risk-adjustable telehealth visits and flexible delivery of outpatient services at home, there will likely be heightened scrutiny on chronic condition coding for 2020 dates of service and beyond. 

The good news is that deferred audits give plans and at-risk providers a chance to review their current compliance programs and take additional measures to ensure future success. Now is the time for risk adjustment programs to evaluate the people, processes, and technology they currently have in place to support audits, and invest in additional resources to protect their program’s performance for years to come. Here are a few areas for risk adjustment and compliance program managers to consider.

In terms of people: Do you have the right analytics and project management team in place to support prospective risk activities? Getting condition coding right before claims processing is the most effective way to ensure accurate, comprehensive risk capture for in-person encounters and telehealth visits.

For retrospective reviews: Do you have enough coders to perform a thorough QA? Quality assurance or audit reviews are your first line of defense against non-compliant retrospective coding, whether your own coders review charts or an external vendor does this work for you. From an audit perspective, your team should allocate dedicated resources to confirm supplemental codes found in chart reviews and assess diagnosis codes submitted on claims. If you don’t have the internal resources to support comprehensive audit reviews, your organization may need to leverage an outside vendor so you’re able to look both ways for HCC adds and deletes.

In terms of processes: Every audit program needs a clear, comprehensive set of guidelines to govern audit reviews. If you haven’t refreshed your guidelines in awhile, now is a great time to make some updates—particularly around telehealth services, which have only recently been made risk-adjustable by CMS. In tandem, work with your analytics team or an external analytics vendor to identify your areas of highest compliance risk, whether those are specific HCCs, individual providers or practices, outside coding vendors, or a particular subset of members. Someone on your team should also be responsible for staying up-to-date on regulatory changes impacting risk adjustment so you can refine your guidelines accordingly. 

Additionally, you may also want to expand your audit preparation from an annual or semi-annual endeavor to a year-round initiative. Year-round retrospective chart reviews can help you improve coding accuracy, optimize coding strategies, and reduce the risk of unsupported HCC submissions. Better yet, your organization might consider investing in concurrent or prospective risk adjustment programs that help providers accurately document and capture diagnosis codes upstream, ensuring appropriate risk capture at the point of service.

Lastly, in terms of technology: Your risk adjustment audit program needs at minimum some kind of analytics solution to analyze previous coding submissions so you can understand education and training needs for providers and coders. Retrospective risk adjustment programs should ideally incorporate an AI-assisted chart review platform to improve coding accuracy and streamline audit reviews. With AI algorithms to point coders to the HCCs with the highest likelihood of noncompliance, your team can focus their review efforts on the charts that pose the greatest potential liability to your program. This also reduces the audit workload on your team so coders can focus their efforts and review more charts before submission deadlines. Additionally, investing in prospective solutions that surface member chronic condition data can help providers proactively assess, document, and code risk-adjusting conditions, reducing reporting gaps and mitigating audit risk associated with retrospective reviews.

Whether your organization has already invested in audit activities or you’re still in the process of building your compliance competency, now is the time to prepare for increased regulatory scrutiny around HCC code submissions. Take this opportunity to review your resources, procedures, and tools so you have everything in place to succeed during future RADVs, IVAs, and other audit reviews.

Looking for an AI-assisted chart review platform to help your program look both ways? Apixio’s HCC Complete solution supports in-house coding teams and full-service coding & audit projects.

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Ashley Taylor Anderson