Centers for Medicare and Medicaid Services (CMS) issued a press release at the end of May stating that they will be ramping up Risk Adjustment Data Validation (RADV) audits. There will be 2000 coders auditing 200 patient charts across 550 Medicare Advantage (MA) plans. The numbers are up from 40 coders auditing 35 patient charts across 30 MA plans prior to these planned audits. These retrospective reviews will occur from 2018-2024 and should be completed by early 2026.
Extrapolation will occur following the audit to recoup the estimated $17 billion in overpayment to MA plans.
Outpatient Clinical Documentation Integrity (CDI) programs support accurate documentation and code assignment with pre-visit reviews, provider education, problem list maintenance, and inclusion of a pre-bill assessment program with the review of claims before they drop to the payer. Additional security can be facilitated by a program where coding experts perform retrospective audits for all Medicare Advantage payers for calendar years dating back to 2018.
Harmony Healthcare can help your organization navigate RADV audit from CMS. Reach out to us to learn about how we can support you.
Additional information on critical CMS updates
