RADV Audit Service

With the RADV pilot completed, CMS will continue to conduct RADV audits to determine whether differences in coding between MA plans and Fee-For-Service providers are the results of coding patterns or of underlying beneficiary health status.

AE’s HCC Risk Adjustment Management provides you with controlled audit and pre-audit services to aid your Plan to become CMS-RADV audit-ready. Our services can be tailored to each Medicare Advantage Plans (MAPs) needs.

AE’s Process for RADV Mock Audit

We simulate, as closely as possible CMS methodology and approach, and assist the Plan in their mock RADV activities. These cases may range from pre-selected members by the Plan or patients treated by targeted providers that the Plan has pre-identified.

Once those cases are identified, AE will work with the Plan to contact the providers and collect data for all pre-identified DOS, examine the supporting documentation and carry out the mock audit or other audit services.

  • Optimize the Plans Risk Adjustment Factor Score
  • Identify ICD-9-CM code assignment errors and enhance current and future coding accuracy.
  • Assessment of medical record documentation for compliance and support of submitted HCC codes.
  • Audit and Identify HCC cases ineligible for CMS reporting due to documentation deficiencies, e.g., provider identifier errors and invalid medical records per CMS guidelines
  • Identifying potential HCC suspects for future CMS reporting
  • Other RADV audit objectives: opportunities for provider education (CDI, coding, etc.), identify providers requiring monitoring because of continuing documentation errors, identify physician practices with high claims error rates (i.e., incorrect ICD-9CM codes), etc.