Compliance has never been more important for retrospective risk adjustment programs. With mounting pressure from the CMS, OIG, DOJ, and other regulatory bodies to crack down on overpayments and fraudulent reporting, organizations are putting their programs at increasing audit risk. But manually looking both ways—that is, reviewing charts to find missing supported HCCs and identifying coded HCCs lacking sufficient evidence—is time-consuming, costly, and unscalable.
Given these challenges, most organizations audit only a fraction of codes submitted to CMS or HHS. In Apixio’s 2018 risk adjustment coder survey, 60% of respondents indicated that their organization performs a QA review on 30% or fewer of all coded charts. This lack of oversight creates a financial and reputation liability for payers participating in government programs.